Summary Report for FSPSAs Ending During the Report Period Center: 52
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 750 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 3 3 1.533333 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 1.533333 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 2.000000 $32.3000 $16.1500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 2.000000 $15.8400 $7.9200
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 2.000000 $63.6200 $31.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 2.000000 $46.2800 $23.1400
OCTH -97165 OT EVAL LOW COMPLEXITY 3 3 3.000000 $174.3300 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 4 4 4.000000 $232.4400 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 3 3 3.000000 $174.3300 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 3.000000 $174.3300 $58.1100
SCREEN-T1023 SCREENING 12 13 13.000000 $701.7400 $53.9800
SPCH -92521 EVAL OF SPEECH FLUENCY 7 7 7.000000 $406.7700 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 3 4 4.000000 $232.4400 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $58.1100 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 5 5 18.000000 $1045.9800 $58.1100
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Subtotal (Total Children Is Unduplicated) 38 47 64.000000 $3358.5100 $52.4800
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $231.6200 $231.6200
CONIF -CONIF CONSULT, ITDS FACE TO FACE 124 157 353.616669 $17680.8500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 71 77 218.333334 $10916.6700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 37 43 99.333334 $4966.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 58 59 140.566669 $7028.3500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 1.266667 $31.6700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 215 249 1152.750001 $62248.5400 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 6 6 15.133333 $817.2000 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 34 35 151.590476 $12327.3200 $81.3200
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 7.285714 $592.4700 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 2 2 8.552381 $556.9300 $65.1200
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 10.857143 $707.0100 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 25 26 80.911906 $6579.7500 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 5 5 17.619048 $1432.7900 $81.3200
PHY -97110HM PT SESSION BY PT ASST 4 4 12.171430 $792.6100 $65.1200
PHY -97110HMGT PT SESSION BY PT ASST 2 2 1.571428 $102.3300 $65.1200
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 2.000000 $918.4400 $459.2200
SENS -V5264 EARMOLD 1 1 1.333333 $24.1700 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 26 26 130.176192 $10585.9300 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 0.400000 $32.5300 $81.3200
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Subtotal (Total Children Is Unduplicated) 278 700 2406.469058 $138573.8400 $57.5800
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Total 750 2472.002391 $141932.3500 $57.4200
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Number of Children (Unduplicated) With at Least One Authorization 294