Summary Report for FSPSAs Ending During the Report Period Center: 54
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 1146 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 7 7 4.865079 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 7 7 4.865079 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AACIS -92597 AAC INTIAL EVAL BY LICENSED SLP 1 1 1.000000 $116.8300 $116.8300
AACIS -92597TL AAC INTIAL EVAL BY LICENSED SLP 1 1 0.216667 $25.3200 $116.8500
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 76 87 73.900004 $3584.1700 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 9 9 6.944444 $428.5400 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 0.272222 $4.1300 $15.1900
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 19 20 14.350000 $348.4200 $24.2800
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 0.255556 $2.7800 $10.8800
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.000000 $23.1400 $23.1400
AUDE -92602 REPROGRAM COCHLEAR IMPLT <7 1 1 0.200000 $12.1500 $60.7300
AUDE -92651 AEP HEARING STATUS DETER I&R 1 1 0.166667 $13.0400 $78.2700
AUDE -V5010 ASSESSMENT FOR HEARING AID 13 13 5.077777 $230.1200 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.133333 $15.4400 $115.7800
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Subtotal (Total Children Is Unduplicated) 111 137 103.516670 $4804.0800 $46.4100
EI Services, Class # 03
AACFIT-92609 AAC FITTING, ADJUST, TRAINING VISIT 4 4 2.433333 $116.6500 $47.9400
AACFIT-92609TL AAC FITTING, ADJUST, TRAINING VISIT 2 2 0.561111 $26.9000 $47.9400
AACFIT-92609TLGT AAC FITTING, ADJUST, TRAINING VISIT 1 1 0.433333 $20.7700 $47.9400
ASST -ASST ASSISTIVE TECHNOLOGY 35 40 63.630159 $318151.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 157 185 146.359921 $7318.0000 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 14 16 17.178571 $858.9300 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 38 41 35.859527 $1792.9900 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 1 1 0.005556 $0.2800 $50.4000
CONIP -CONIP CONSULT, ITDS PHONE 1 2 1.155556 $28.8900 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 73 77 94.338887 $4716.9500 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 2 2 6.563492 $328.1800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 52 53 54.330955 $2716.5500 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 1 1 0.777778 $38.8900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 111 119 119.422228 $5971.1200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 0.400000 $10.0000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 12 14 34.899998 $942.3000 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 259 283 1405.933335 $75920.4500 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 6 7 39.000000 $2106.0000 $54.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 9 9 17.811111 $213.7300 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 38 39 209.587302 $17043.6600 $81.3200
OCCT -97530GT OT SESSION BY LICENSED OT 3 3 11.571429 $940.9900 $81.3200
OCCT -97530TL OT SESSION BY LICENSED OT 29 32 140.790475 $11449.1100 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 12 12 42.185715 $3430.5400 $81.3200
PHY -97110TL PT SESSION BY LICENSED PT 20 21 114.857143 $9340.2000 $81.3200
SENS -V5264 EARMOLD 2 2 2.214286 $40.1500 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 20 22 115.314287 $9377.3500 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 8 9 39.471430 $3209.8200 $81.3200
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 3 3 14.142858 $1150.0900 $81.3200
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Subtotal (Total Children Is Unduplicated) 427 1002 2731.229776 $477260.4700 $174.7400
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Total 1146 2839.611525 $482064.5500 $169.7600
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Number of Children (Unduplicated) With at Least One Authorization 434