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 532 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 -92552 PURE TONE AUDIOMETRY -AIR ONLY 19 19 19.000000 $407.7400 $21.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 17 17 17.000000 $274.5500 $16.1500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 17 17 17.000000 $134.6400 $7.9200
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 17 17 17.000000 $540.7700 $31.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 17 17 17.000000 $393.3800 $23.1400
NUTR -97802 NUTRITIONAL EVAL, INITIAL 5 5 7.466666 $373.3300 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 5 6 6.000000 $348.6600 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 6 7 7.000000 $406.7700 $58.1100
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Subtotal (Total Children Is Unduplicated) 34 105 107.466666 $2879.8400 $26.8000
EI Services, Class # 03
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 74 83 506.725402 $27363.1800 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 20 20 94.464288 $7681.8100 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 17 20 85.471429 $6950.5200 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 25 25 141.357143 $11495.1500 $81.3200
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Subtotal (Total Children Is Unduplicated) 226 422 1054.618268 $64820.6900 $61.4600
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Total 532 1163.929379 $67700.5300 $58.1700
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Number of Children (Unduplicated) With at Least One Authorization 234