Summary Report for FSPSAs Ending During the Report Period Center: 04
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: 07-01-24 and 09-30-24 Date of Report: 04-06-25 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1687 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 39 40 20.047618 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 39 40 20.047618 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $61.7100 $61.7100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 49 55 12.770638 $742.1200 $58.1100
PSTH -97161TL PT EVAL LOW COMPLEXITY 1 1 0.061111 $3.5500 $58.1000
PSTH -97163TL PT EVAL HIGH COMPLEXITY 20 22 5.511113 $320.2600 $58.1100
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.000000 $15.1100 $15.1100
SPCH -92521TL EVAL OF SPEECH FLUENCY 29 31 7.116667 $413.5500 $58.1100
SPCH -92522TL EVAL OF SPCH SOUND PROD 1 1 0.077778 $4.5200 $58.1300
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Subtotal (Total Children Is Unduplicated) 65 112 27.537307 $1560.8300 $56.6800
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 2.000000 $463.2400 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 15 51 12.355554 $617.7700 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 5 5 2.366667 $118.3400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 6 6 1.909523 $95.4800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 0.766667 $38.3400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 5 5 0.544445 $27.2300 $50.0100
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 111 150 759.714270 $20512.3200 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 532 562 3950.999996 $213354.0300 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 1.142857 $61.7200 $54.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 531 565 3984.619047 $47815.4300 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 3.142857 $255.5800 $81.3200
OCCT -97530TL OT SESSION BY LICENSED OT 64 76 409.571429 $33306.3500 $81.3200
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 0.285714 $23.2300 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 1 1 6.000000 $487.9200 $81.3200
PHY -97110TL PT SESSION BY LICENSED PT 36 44 265.000000 $21549.8200 $81.3200
SENS -V5264 EARMOLD 1 1 1.000000 $18.1300 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 3.214286 $261.3900 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 52 62 297.357143 $24181.1000 $81.3200
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Subtotal (Total Children Is Unduplicated) 639 1535 9701.990455 $363187.3900 $37.4300
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Total 1687 9749.575380 $364748.2200 $37.4100
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Number of Children (Unduplicated) With at Least One Authorization 672