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: 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 611 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 12 12 12.911112 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 12 12 12.911112 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 28 31 23.312697 $1130.6600 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $61.7100 $61.7100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 2.000000 $48.5600 $24.2800
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.272222 $12.3400 $45.3200
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Subtotal (Total Children Is Unduplicated) 31 34 26.584919 $1253.2600 $47.1400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 10 10 11.233333 $56166.5000 $4999.9900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 154 176 162.037698 $8101.8800 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 9 11 9.850000 $492.5000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 52 69 81.203173 $4060.1500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 67 70 68.735713 $3436.7800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.277778 $6.9500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 51 55 55.756349 $2787.8100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 114 120 99.285711 $4964.2700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 7 3.977777 $99.4400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 26 28 131.314285 $7090.9600 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 3 3 22.928571 $1238.1400 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 3 3 20.428572 $1661.2500 $81.3200
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 0.071429 $5.8100 $81.2900
OCCT -97530TL OT SESSION BY LICENSED OT 2 2 1.571429 $127.7900 $81.3200
OCCT -97530TLHM OT SESSION BY OT ASST 1 1 4.785714 $311.6400 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 4 4 4.742857 $385.6900 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 3 14.571429 $1184.9500 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 2.500000 $203.3000 $81.3200
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Subtotal (Total Children Is Unduplicated) 306 565 695.271818 $92325.8000 $132.7900
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Total 611 734.767849 $93579.0700 $127.3600
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Number of Children (Unduplicated) With at Least One Authorization 319