Summary Report for FSPSAs Initiated During the Report Period Center: 54
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 1214 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 11 11 10.371429 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 11 11 10.371429 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AACIS -92597 AAC INTIAL EVAL BY LICENSED SLP 2 2 2.111111 $246.6400 $116.8300
AACIS -92597TL AAC INTIAL EVAL BY LICENSED SLP 1 1 0.294444 $34.3900 $116.8100
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 64 74 76.094444 $3690.5800 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 11 11 10.888889 $671.9500 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 1.000000 $15.1900 $15.1900
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.177778 $4.6300 $26.0400
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 26 26 20.627779 $500.8500 $24.2800
AUDE -92602 REPROGRAM COCHLEAR IMPLT <7 1 1 0.311111 $18.8900 $60.7300
AUDE -V5010 ASSESSMENT FOR HEARING AID 16 16 5.527777 $250.5200 $45.3200
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Subtotal (Total Children Is Unduplicated) 114 133 117.033333 $5433.6400 $46.4300
EI Services, Class # 03
AACFIT-92609 AAC FITTING, ADJUST, TRAINING VISIT 6 6 2.772222 $132.9000 $47.9400
AACFIT-92609TLGT AAC FITTING, ADJUST, TRAINING VISIT 1 1 0.588889 $28.2300 $47.9400
ASST -ASST ASSISTIVE TECHNOLOGY 34 41 60.722222 $303611.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 175 190 144.621034 $7231.0700 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 14 16 17.178571 $858.9300 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 38 44 54.950792 $2747.5300 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 1 1 0.005556 $0.2800 $50.4000
CONOF -CONOF CONSULT, OT, FACE TO FACE 86 88 102.119840 $5105.9700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 1.800000 $45.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 51 52 54.447614 $2722.3600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 114 123 137.319047 $6865.9300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 5 2.555555 $63.8900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 8 8 74.714286 $2017.2800 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 305 323 1600.157157 $86408.4500 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 13 13 74.928573 $4046.1400 $54.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1 1 2.142857 $25.7100 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 39 43 196.942857 $16015.4000 $81.3200
OCCT -97530GO OT SESSION BY LICENSED OT 1 1 0.428571 $34.8500 $81.3300
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.000000 $65.1200 $65.1200
OCCT -97530TL OT SESSION BY LICENSED OT 23 24 99.714287 $8108.7500 $81.3200
OCCT -97530TLGO OT SESSION BY LICENSED OT 1 1 2.000000 $162.6400 $81.3200
OCCT -97530TLHM OT SESSION BY OT ASST 5 5 13.500001 $879.1100 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 15 17 67.185713 $5463.5400 $81.3200
PHY -97110TL PT SESSION BY LICENSED PT 25 25 124.704764 $10140.9900 $81.3200
SENS -V5264 EARMOLD 1 1 2.000000 $36.2600 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 27 29 161.546033 $13136.9300 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 7 7 23.214286 $1887.7900 $81.3200
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 2 2 1.800000 $146.3800 $81.3200
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Subtotal (Total Children Is Unduplicated) 474 1070 3025.060727 $477988.4300 $158.0100
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Total 1214 3152.465489 $483422.0700 $153.3500
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Number of Children (Unduplicated) With at Least One Authorization 483