Summary Report for FSPSAs Initiated During the Report Period Center: 10
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 3103 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 5 5 1.844445 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 5 5 1.844445 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 1.000000 $15.1900 $15.1900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 283 291 291.000000 $6244.8600 $21.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 276 282 282.000000 $4554.3000 $16.1500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 274 280 280.000000 $2217.6000 $7.9200
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 274 280 280.000000 $8906.8000 $31.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 274 280 280.000000 $6479.2000 $23.1400
NUTR -97802 NUTRITIONAL EVAL, INITIAL 5 5 7.466666 $373.3300 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 25 30 35.420635 $2058.3000 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 4 4 4.000000 $232.4400 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 32 36 36.000000 $2091.9600 $58.1100
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Subtotal (Total Children Is Unduplicated) 338 1489 1496.887301 $33173.9800 $22.1600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 8 8.000000 $40000.0000 $5000.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 128 137 113.544448 $5677.2400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 22 24 24.344444 $1217.2200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 28 28 11.811113 $590.5700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 81 85 76.900001 $3845.0100 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 612 742 4273.540528 $230771.1700 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 146 169 1007.107151 $81897.9100 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 171 194 877.940477 $71394.0700 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 196 221 899.986508 $73186.8800 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 6.285714 $511.1500 $81.3200
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Subtotal (Total Children Is Unduplicated) 860 1609 7299.460384 $509091.2000 $69.7400
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Total 3103 8798.192130 $542265.1800 $61.6300
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Number of Children (Unduplicated) With at Least One Authorization 888