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: 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 1101 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 2.500000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 2.500000 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 76 85 86.755557 $4207.6500 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 11 11 9.022223 $556.7700 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 3 3 1.038889 $15.7800 $15.1900
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.272222 $7.0900 $26.0400
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 19 19 15.694446 $381.0700 $24.2800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.000000 $31.8100 $31.8100
AUDE -92602 REPROGRAM COCHLEAR IMPLT <7 1 1 0.461111 $28.0000 $60.7300
AUDE -V5010 ASSESSMENT FOR HEARING AID 12 12 3.400001 $154.0900 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 0.566667 $65.6300 $115.8200
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Subtotal (Total Children Is Unduplicated) 115 135 118.211116 $5447.8900 $46.0900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 17 19 20.494445 $102472.5000 $5000.0100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 165 195 154.966668 $7748.3400 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 11 12 11.000000 $550.0000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 34 37 28.444446 $1422.2300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 89 90 97.884126 $4894.2100 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 41 42 32.968255 $1648.4100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 104 110 131.771434 $6588.6200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 1.422222 $35.5600 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 6 7 61.714284 $1666.2900 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 278 290 1359.842852 $73431.5700 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 14 14 66.571428 $3594.8600 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 31 33 140.820635 $11451.5500 $81.3200
OCCT -97530TL OT SESSION BY LICENSED OT 27 28 125.323809 $10191.3700 $81.3200
OCCT -97530TLGO OT SESSION BY LICENSED OT 3 3 15.571428 $1266.2700 $81.3200
OCCT -97530TLHM OT SESSION BY OT ASST 2 2 12.285714 $800.0500 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 13 13 64.466666 $5242.4300 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 1 1 12.428571 $1010.6900 $81.3200
PHY -97110TL PT SESSION BY LICENSED PT 25 26 90.057142 $7323.4700 $81.3200
SENS -V5060 BEHIND EAR HEARING AID 1 1 0.166667 $38.2800 $229.6600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.400000 $183.6900 $459.2200
SENS -V5264 EARMOLD 2 2 0.566667 $10.2700 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 24 26 127.319045 $10353.5900 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 8 8 50.552380 $4110.9200 $81.3200
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 2 2 4.533334 $368.6600 $81.3200
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Subtotal (Total Children Is Unduplicated) 458 964 2611.572218 $256403.8100 $98.1800
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Total 1101 2732.283334 $261851.7000 $95.8400
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Number of Children (Unduplicated) With at Least One Authorization 460