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 252 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
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Subtotal (Total Children Is Unduplicated) 24 24 29.861110 $0.0000 $0.0000
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 -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 4 5 3.244444 $78.7700 $24.2800
EXIT -EXIT COS Exit 1 1 1.000000 $50.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 13 16 12.127778 $528.1500 $43.5500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 6 6.000000 $30000.0000 $5000.0000
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 12 12 89.352384 $4825.0200 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 2.800000 $151.2000 $54.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 22 23 123.866667 $1486.4000 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 6.857143 $557.6200 $81.3200
OCCT -97530TL OT SESSION BY LICENSED OT 2 2 11.000000 $894.5200 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 1 1 1.133333 $92.1600 $81.3200
PHY -97110TL PT SESSION BY LICENSED PT 1 1 2.366667 $192.4600 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 3 7.052382 $573.5000 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 2.700000 $219.5600 $81.3200
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Subtotal (Total Children Is Unduplicated) 152 212 490.889692 $50586.6300 $103.0500
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Total 252 532.878580 $51114.7700 $95.9200
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Number of Children (Unduplicated) With at Least One Authorization 178