Summary Report for FSPSAs Initiated During the Report Period Center: 52
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: 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 739 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 2 2 0.444444 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 0.444444 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.3200 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.000000 $231.6200 $115.8100
OCTH -97165 OT EVAL LOW COMPLEXITY 5 5 5.000000 $290.5500 $58.1100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 3.000000 $174.3300 $58.1100
SCREEN-T1023 SCREENING 13 13 13.000000 $701.7400 $53.9800
SPCH -92521 EVAL OF SPEECH FLUENCY 7 7 7.000000 $406.7700 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 4.000000 $232.4400 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $58.1100 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 7 7 43.485714 $2526.9500 $58.1100
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Subtotal (Total Children Is Unduplicated) 42 48 85.485714 $5016.4900 $58.6800
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 2.000000 $100.0000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 139 165 409.383334 $20469.1700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 79 81 225.666666 $11283.3300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 36 46 172.400001 $8620.0100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 56 58 162.333333 $8116.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 2 1.166667 $29.1700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 224 245 1198.238107 $64704.8900 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 4 4 29.095238 $1571.1500 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 28 28 144.714286 $11768.1800 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 23 24 119.319051 $9703.0500 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 2 2 9.285714 $755.1100 $81.3200
PHY -97110HM PT SESSION BY PT ASST 5 6 33.742859 $2197.3400 $65.1200
PHY -97110HMGT PT SESSION BY PT ASST 1 1 12.857143 $837.2500 $65.1200
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 2.000000 $459.2200 $229.6100
SENS -V5264 EARMOLD 1 1 0.022222 $0.4000 $18.1100
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 23 23 99.685715 $8106.4400 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 12.142857 $987.4600 $81.3200
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Subtotal (Total Children Is Unduplicated) 285 689 2634.053193 $149708.8300 $56.8400
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Total 739 2719.983351 $154725.3300 $56.8800
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Number of Children (Unduplicated) With at Least One Authorization 301