Summary Report for FSPSAs Initiated During the Report Period Center: 07
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: 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 842 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 24 24 27.442064 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 24 24 27.442064 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 0.700000 $10.6300 $15.1900
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 1.811111 $27.5100 $15.1900
OCTH -97165 OT EVAL LOW COMPLEXITY 5 5 4.144444 $240.8300 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 2 1.344444 $78.1200 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 0.111111 $6.4600 $58.1000
SPCH -92521 EVAL OF SPEECH FLUENCY 5 5 2.977778 $173.0400 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 4.000000 $232.4400 $58.1100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.077778 $4.5200 $58.1300
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Subtotal (Total Children Is Unduplicated) 20 23 17.166666 $889.7700 $51.8300
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 2.000000 $463.2400 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 136 161 129.458743 $6472.9900 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 7 7 5.750000 $287.5000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 0.750000 $18.7500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 230 261 582.141274 $29107.0900 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 2 2 5.266667 $263.3400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 116 125 238.642857 $11932.1500 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 2 2 3.500000 $175.0000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 44 46 103.295239 $5164.7700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 116 130 210.155555 $10507.7800 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 3 3 3.733334 $186.6700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 36 38 278.228572 $15024.3400 $54.0000
INTR -T1013 INTERPRETER 2 2 11.857143 $592.8600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 10.428571 $848.0500 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 2 2 19.142857 $1556.7000 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 1 1 8.857143 $720.2600 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 10 10 71.714287 $5831.8100 $81.3200
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 4.000000 $260.4800 $65.1200
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Subtotal (Total Children Is Unduplicated) 328 795 1688.922242 $89413.7600 $52.9400
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Total 842 1733.530972 $90303.5300 $52.0900
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Number of Children (Unduplicated) With at Least One Authorization 349