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: 01-01-25 and 03-31-25 Date of Report: 04-06-25 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1168 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 14 15 17.760317 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 14 15 17.760317 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AACIS -92597 AAC INTIAL EVAL BY LICENSED SLP 2 2 2.327778 $271.9600 $116.8300
AACIS -92597TL AAC INTIAL EVAL BY LICENSED SLP 1 1 0.222222 $25.9600 $116.8200
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 51 58 51.972224 $2520.6600 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 16 16 16.438889 $1014.4400 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 1.000000 $15.1900 $15.1900
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 26 26 17.027778 $413.4400 $24.2800
AUDE -V5010 ASSESSMENT FOR HEARING AID 18 18 6.205556 $281.2400 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.200000 $23.1600 $115.8100
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Subtotal (Total Children Is Unduplicated) 105 123 95.394447 $4566.0500 $47.8600
EI Services, Class # 03
AACFIT-92609 AAC FITTING, ADJUST, TRAINING VISIT 8 8 4.027779 $193.1000 $47.9400
AACFIT-92609TLGT AAC FITTING, ADJUST, TRAINING VISIT 1 1 0.444444 $21.3000 $47.9400
ASST -ASST ASSISTIVE TECHNOLOGY 26 31 51.944445 $259722.5000 $5000.0100
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.688889 $159.5600 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 164 190 157.013889 $7850.7000 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 10 12 10.977778 $548.8900 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 50 57 50.373014 $2518.6400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 80 82 75.629370 $3781.4900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 1.155555 $28.8900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 50 53 40.455561 $2022.7900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 111 114 110.679365 $5533.9800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 6 7 3.155556 $78.8900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 19.571429 $528.4300 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 272 291 1264.171432 $68265.2500 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 20 20 109.357144 $5905.2800 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 28 28 154.914284 $12597.6600 $81.3200
OCCT -97530GO OT SESSION BY LICENSED OT 2 2 12.071429 $981.6500 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 2 2 8.571428 $558.1800 $65.1200
OCCT -97530TL OT SESSION BY LICENSED OT 24 24 114.749206 $9331.4000 $81.3200
OCCT -97530TLGO OT SESSION BY LICENSED OT 10 11 75.333334 $6126.1000 $81.3200
OCCT -97530TLHM OT SESSION BY OT ASST 7 7 34.214286 $2228.0400 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 14 14 68.290478 $5553.3800 $81.3200
PHY -97110TL PT SESSION BY LICENSED PT 20 23 90.928571 $7394.2900 $81.3200
PHY -97110TLGT PT SESSION BY LICENSED PT 1 1 2.285714 $185.8700 $81.3200
SENS -V5060 BEHIND EAR HEARING AID 1 1 0.200000 $45.9200 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 2.000000 $918.4400 $459.2200
SENS -V5264 EARMOLD 3 3 7.800000 $141.4100 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 26 27 107.807938 $8766.9400 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 1.214286 $98.7500 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 11 11 37.800000 $3073.9000 $81.3200
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 2 2 2.928572 $238.1500 $81.3200
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Subtotal (Total Children Is Unduplicated) 453 1030 2620.755176 $415399.7500 $158.5000
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Total 1168 2733.909940 $419965.8000 $153.6100
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Number of Children (Unduplicated) With at Least One Authorization 466