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: 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 1057 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 4 4 2.622222 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 4 4 2.622222 $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
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 36 43 36.461112 $1768.3700 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 12 12 11.555556 $713.1000 $61.7100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 19 19 11.861113 $287.9900 $24.2800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.361111 $11.4900 $31.8100
AUDE -V5010 ASSESSMENT FOR HEARING AID 11 11 4.438889 $201.1700 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 1.605556 $185.9400 $115.8100
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 72 90 67.283337 $3284.8900 $48.8200
EI Services, Class # 03
AACFIT-92609 AAC FITTING, ADJUST, TRAINING VISIT 3 3 2.800000 $134.2300 $47.9400
AACFIT-92609TL AAC FITTING, ADJUST, TRAINING VISIT 1 1 0.544444 $26.1000 $47.9400
ASST -ASST ASSISTIVE TECHNOLOGY 14 14 24.661111 $123305.5000 $5000.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.000000 $69.3500 $69.3500
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 9.857143 $683.5900 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 1.988889 $460.6700 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 163 193 158.512700 $7925.6400 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 12 13 10.433333 $521.6700 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 37 39 41.069047 $2053.4600 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 1 1 0.238889 $11.9500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 77 78 64.530158 $3226.5100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.288889 $7.2200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 47 50 64.549998 $3227.5000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 105 109 96.458729 $4822.9300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 1.077778 $26.9500 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 10 10 42.823810 $1156.2500 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 258 267 1386.539686 $74873.1200 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 24 24 122.357144 $6607.2900 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 21 22 104.639682 $8509.3000 $81.3200
OCCT -97530GO OT SESSION BY LICENSED OT 2 2 5.571429 $453.0700 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 1 1 3.857143 $251.1700 $65.1200
OCCT -97530TL OT SESSION BY LICENSED OT 16 16 93.142858 $7574.3800 $81.3200
OCCT -97530TLGO OT SESSION BY LICENSED OT 18 19 113.500001 $9229.8100 $81.3200
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 0.966667 $78.6100 $81.3200
OCCT -97530TLHM OT SESSION BY OT ASST 8 8 42.571428 $2772.2500 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 9 9 -11.000001 $-894.5000 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 3 3 12.428572 $1010.6900 $81.3200
PHY -97110TL PT SESSION BY LICENSED PT 20 20 40.104762 $3261.3200 $81.3200
PHY -97110TLGT PT SESSION BY LICENSED PT 2 2 10.428571 $848.0500 $81.3200
SENS -V5060 BEHIND EAR HEARING AID 1 1 0.855556 $196.4500 $229.6200
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 3 3 2.750000 $1262.8600 $459.2200
SENS -V5264 EARMOLD 4 4 7.666667 $139.0000 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 23 26 138.704762 $11279.4800 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 6.928571 $563.4300 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 10 11 37.052380 $3013.0900 $81.3200
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 3 3 9.857142 $801.5900 $81.3200
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 434 963 2649.757938 $279489.9600 $105.4800
-------------------------------------------------------------------------------------------------------------------------------------
Total 1057 2719.663497 $282774.8500 $103.9700
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 437