Summary Report for FSPSAs Ending During the Report Period Center: 07
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: 07-01-24 and 09-30-24 Date of Report: 04-06-25 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 880 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 14 14.676192 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 14 14 14.676192 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 2 2 5.788888 $87.9300 $15.1900
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.155556 $2.3600 $15.1900
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 24.857143 $575.1900 $23.1400
OCTH -97165 OT EVAL LOW COMPLEXITY 4 5 4.366667 $253.7500 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 0.038889 $2.2600 $58.1300
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 1.000000 $58.1100 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 2.000000 $116.2200 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 3.038889 $176.5900 $58.1100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $58.1100 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $58.1100 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 1.142857 $66.4100 $58.1100
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Subtotal (Total Children Is Unduplicated) 15 20 44.388889 $1455.0500 $32.7800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 135 159 128.903980 $6445.2500 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 6 6 4.750000 $237.5000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 5.133333 $128.3300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 245 275 585.704765 $29285.2500 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 2 2 5.533334 $276.6700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 124 131 249.199999 $12460.0000 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 3 3 3.566667 $178.3400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.833333 $20.8300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 44 47 91.500000 $4575.0000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 140 162 298.566667 $14928.3400 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 2 2 1.900000 $95.0000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 1.366667 $34.1700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 32 34 288.809522 $15595.7300 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 7 7 49.571428 $4031.1500 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 11 11 40.428572 $3287.6600 $81.3200
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 1 1 22.285714 $1451.2400 $65.1200
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Subtotal (Total Children Is Unduplicated) 362 846 1779.053981 $98030.4600 $55.1000
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Total 880 1838.119062 $99485.5100 $54.1200
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Number of Children (Unduplicated) With at Least One Authorization 377