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 628 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
----------------------------------------------------------------------------
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 1 1 1.000000 $61.7100 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 0.122222 $1.8600 $15.1900
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 2.272222 $55.1700 $24.2800
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 79 89 90.150001 $4326.3900 $47.9900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 11 13 15.605556 $78028.0000 $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
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 20 21 101.319048 $5471.2300 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 1.571429 $84.8600 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 6 6 26.076192 $2120.5200 $81.3200
OCCT -97530TLGO OT SESSION BY LICENSED OT 1 1 4.500000 $365.9400 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 1 1 6.428571 $522.7700 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 6 6 21.933331 $1783.6200 $81.3200
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 303 537 635.891278 $111264.3000 $174.9700
-------------------------------------------------------------------------------------------------------------------------------------
Total 628 728.541279 $115590.6900 $158.6600
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 309