Summary Report for FSPSAs Ending During the Report Period Center: 03
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: 10-01-24 and 12-31-24 Date of Report: 03-31-25 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 637 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 43 43 21.188888 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 43 43 21.188888 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 5 6 6.000000 $291.0000 $48.5000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 1.322222 $42.0600 $31.8100
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.100000 $11.5800 $115.8100
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.122222 $7.1000 $58.1000
OCTH -97167 OT EVAL HIGH COMPLEXITY 15 16 6.833334 $397.0900 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 26 27 12.422221 $721.8500 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 32 34 17.555559 $1020.1700 $58.1100
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Subtotal (Total Children Is Unduplicated) 73 88 45.355558 $2548.9600 $56.2000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 7 8 5.616667 $28083.5000 $5000.0300
CONIF -CONIF CONSULT, ITDS FACE TO FACE 6 6 5.055556 $252.7800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 27 30 34.700001 $1735.0100 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 19 19 22.333335 $1116.6800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 40 42 44.411110 $2220.5500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 246 289 1155.255539 $62383.8800 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 20 24 80.371428 $6535.8100 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 38 40 128.242858 $10428.7200 $81.3200
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.024658 $5.6700 $230.0000
SENS -V5264 EARMOLD 1 1 0.024658 $0.4500 $18.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 40 46 174.869842 $14220.4000 $81.3200
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Subtotal (Total Children Is Unduplicated) 344 506 1650.905652 $126983.4300 $76.9200
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Total 637 1717.450098 $129532.4000 $75.4200
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Number of Children (Unduplicated) With at Least One Authorization 388