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: 01-01-25 and 03-31-25 Date of Report: 04-06-25 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 796 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 23 23 22.933331 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 23 23 22.933331 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 0.322222 $4.8900 $15.1900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 3.857143 $82.7700 $21.4600
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.511111 $7.7600 $15.1900
OCTH -97165 OT EVAL LOW COMPLEXITY 5 5 3.650000 $212.1000 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 1.000000 $58.1100 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 1.466667 $85.2300 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 0.222222 $12.9100 $58.1000
SPCH -92521 EVAL OF SPEECH FLUENCY 4 4 0.555556 $32.2900 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 3.194444 $185.6300 $58.1100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.416667 $24.2100 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 2 2 15.571429 $904.8500 $58.1100
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Subtotal (Total Children Is Unduplicated) 20 23 30.767461 $1610.7700 $52.3500
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 113 146 136.705165 $6835.2900 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 9 9 9.000000 $450.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 12 13 11.750000 $293.7500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 209 235 519.929366 $25996.4800 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 4 5 11.066667 $553.3400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 98 107 198.014285 $9900.7200 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 4 4 6.900000 $345.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 3 1.866667 $46.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 41 43 77.109523 $3855.4800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 110 117 209.061905 $10453.1000 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 3 3 3.466666 $173.3300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 41 41 293.457142 $15846.6900 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 2.000000 $108.0000 $54.0000
INTR -T1013 INTERPRETER 1 1 8.428571 $421.4300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 5 5 45.857143 $3729.1000 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 3 3 21.000000 $1707.7200 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 10 10 46.428573 $3775.5700 $81.3200
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 30.571428 $1990.8200 $65.1200
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 1 1 0.285714 $18.6000 $65.1200
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Subtotal (Total Children Is Unduplicated) 308 750 1634.898815 $86964.3100 $53.1900
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Total 796 1688.599607 $88575.0700 $52.4500
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Number of Children (Unduplicated) With at Least One Authorization 329