Summary Report for FSPSAs Initiated During the Report Period Center: 53
This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start 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 starting 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 650 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 24 24 29.861110 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 1.033333 $38.4400 $37.2000
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Subtotal (Total Children Is Unduplicated) 25 25 30.894443 $38.4400 $1.2400
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 8 8 6.594445 $319.8300 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 1.288889 $79.5400 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 0.461111 $7.0000 $15.1900
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 39 40 21.727778 $527.5500 $24.2800
EXIT -EXIT COS Exit 1 1 1.000000 $50.0000 $50.0000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 1.500000 $89.8800 $59.9200
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 17.714286 $1029.3800 $58.1100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 1 2.857143 $166.0300 $58.1100
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Subtotal (Total Children Is Unduplicated) 52 55 53.143652 $2269.2100 $42.7000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 9 10 8.683334 $43417.0000 $5000.0400
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 2.000000 $463.2400 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 19 26 16.500000 $825.0000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 4 4 5.933333 $296.6700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 34 35 86.151586 $4307.5800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 4 4 6.883334 $172.0900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 39 40 58.126987 $2906.3600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 44 45 59.293653 $2964.6900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 6 7 4.872223 $121.8100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 211 218 1158.595252 $62564.0700 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 5 5 26.438096 $1427.6600 $54.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 22 23 123.866667 $1486.4000 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 22 23 127.309526 $10352.7900 $81.3200
OCCT -97530TL OT SESSION BY LICENSED OT 33 34 184.678574 $15018.0600 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 15 15 73.419049 $5970.4200 $81.3200
PHY -97110TL PT SESSION BY LICENSED PT 16 16 81.309527 $6612.0800 $81.3200
PHY -97110TLGT PT SESSION BY LICENSED PT 1 1 3.285714 $267.1900 $81.3200
SENS -V5264 EARMOLD 2 2 1.088889 $19.7400 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 19 20 113.604764 $9238.3300 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 23.276191 $1892.8100 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 35 37 175.752383 $14292.1800 $81.3200
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Subtotal (Total Children Is Unduplicated) 372 570 2341.069082 $184616.1500 $78.8600
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Total 650 2425.107177 $186923.8000 $77.0800
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Number of Children (Unduplicated) With at Least One Authorization 398