Summary Report for FSPSAs Ending During the Report Period Center: 53
This report shows the total number of units/fees for FSPSAs ending during the report period.
(i.e., end date of service authorization occurs during the report period). This report does not
represent all FSPSAs that overlap the report period. Note that service authorization periods may
range from 1 to 12 months and may vary in intensity from child to child.
FSPSAs ending between: 04-01-24 and 06-30-24 Date of Report: 04-12-25 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 694 FSPSA's found
Services Cpt Code Number of Number of Total Units Total Cost of Avg Fee
Children Records Authorized Auth Services Per Unit Auth
Service Coordination, Class # 01
SCONLY-SCONLY *SERVICE COORDINATION ONLY 20 20 25.773810 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 20 20 25.773810 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 8 9 8.133333 $394.4700 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.288889 $17.8300 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 1.000000 $15.1900 $15.1900
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 36 36 21.616669 $524.8600 $24.2800
EXIT -EXIT COS Exit 2 2 2.000000 $100.0000 $50.0000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 1.500000 $89.8800 $59.9200
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 1 11.571429 $672.4100 $58.1100
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Subtotal (Total Children Is Unduplicated) 49 51 46.110320 $1814.6400 $39.3500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 11 16 14.455556 $72278.0000 $5000.0200
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.211111 $48.9000 $231.6100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 19 26 16.500000 $825.0000 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 1 1 1.000000 $50.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 2.700000 $67.5000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 2 2 2.333333 $116.6700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 27 28 52.534125 $2626.6900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.666667 $66.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 33 33 40.202380 $2010.1200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 40 44 80.576191 $4028.8100 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 1 1 1.133333 $56.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 5 7.477778 $186.9500 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 182 191 1011.047617 $54596.5500 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 15 15 50.161906 $2708.7500 $54.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 62 84 403.111113 $4837.3300 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 27 28 148.285712 $12058.6100 $81.3200
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 2.714286 $220.7300 $81.3200
OCCT -97530TL OT SESSION BY LICENSED OT 35 36 205.904762 $16744.1900 $81.3200
OCCT -97530TLGT OT SESSION BY LICENSED OT 2 2 2.600000 $211.4300 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 9 9 61.742855 $5020.9300 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 1 1 2.200000 $178.9000 $81.3200
PHY -97110TL PT SESSION BY LICENSED PT 16 17 78.333332 $6370.0600 $81.3200
PHY -97110TLGT PT SESSION BY LICENSED PT 2 2 12.428572 $1010.6900 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 28 29 128.180952 $10423.6900 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 1.500000 $121.9800 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 39 44 196.123809 $15948.7800 $81.3200
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 4 4 16.047619 $1304.9900 $81.3200
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Subtotal (Total Children Is Unduplicated) 370 623 2542.173009 $214119.5700 $84.2300
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Total 694 2614.057139 $215934.2100 $82.6100
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Number of Children (Unduplicated) With at Least One Authorization 397