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: 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 1599 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 20 20 14.083334 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 20 20 14.083334 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 25 25 12.850000 $792.9700 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 10 10 7.527777 $114.3500 $15.1900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 11 11 6.955555 $149.2700 $21.4600
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 4 4 2.388888 $58.0000 $24.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.866667 $6.8600 $7.9200
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 6 6 5.077778 $161.5200 $31.8100
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 21 21 10.555556 $160.3400 $15.1900
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 13 13 7.716667 $178.5600 $23.1400
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 0.011111 $0.6700 $59.8600
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 0.011111 $0.9000 $80.9000
OCTF -97168 OT RE-EVAL EST PLAN CARE 4 4 4.000000 $232.4400 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 23 23 13.877776 $806.4300 $58.1100
OCTH -97165GT OT EVAL LOW COMPLEXITY 2 2 0.144445 $8.4000 $58.1300
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 1.277778 $74.2500 $58.1100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 0.188889 $10.9800 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 7 7 4.677778 $271.8300 $58.1100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 1 1 0.238889 $13.8800 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 6 6 6.000000 $348.6600 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 11 12 7.844444 $455.8400 $58.1100
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 1 1 0.294444 $17.1100 $58.1000
PSTH -97163 PT EVAL HIGH COMPLEXITY 6 6 3.900000 $226.6300 $58.1100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97163TLGT PT EVAL HIGH COMPLEXITY 2 2 0.277778 $16.1400 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 43 45 31.738890 $1844.3500 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 2 2 1.400000 $81.3500 $58.1100
SPCH -92522 EVAL OF SPCH SOUND PROD 5 5 3.166666 $184.0100 $58.1100
SPCH -92522GT EVAL OF SPCH SOUND PROD 1 1 2.000000 $116.2200 $58.1100
SPCH -92522TL EVAL OF SPCH SOUND PROD 1 1 0.355556 $20.6600 $58.1200
SPCH -92522TLGT EVAL OF SPCH SOUND PROD 1 1 0.144444 $8.3900 $58.0900
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 15 15 8.661111 $503.3000 $58.1100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $58.1100 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 12 13 13.000000 $755.4300 $58.1100
SPCH -92610GT EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 2.000000 $116.2200 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 10 12 104.428571 $6068.3500 $58.1100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 1 7.714286 $448.2800 $58.1100
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Subtotal (Total Children Is Unduplicated) 198 261 275.292855 $14485.0300 $52.6200
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 111 143 120.829769 $6041.5200 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 9 9 9.000000 $450.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 16 19 19.416667 $485.4200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 188 213 564.072228 $28203.6400 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 6 7 8.466666 $423.3300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 91 99 199.438098 $9971.9200 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 4 5 7.266667 $363.3400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.233333 $55.8300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 50 52 121.433334 $6071.6700 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 2 2 2.700000 $135.0000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.066667 $51.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 94 104 184.733331 $9236.6600 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 2 2 1.766667 $88.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 2.066667 $51.6700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 446 469 3600.471463 $194425.4200 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 47 49 321.819049 $17378.2300 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 30 31 239.000003 $19435.4700 $81.3200
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 25.142857 $2044.6200 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 8 8 45.771429 $2980.6400 $65.1200
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 4.571429 $297.6900 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 24 25 182.661905 $14854.0700 $81.3200
PHY -97110TLGT PT SESSION BY LICENSED PT 1 1 7.571429 $615.7100 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 59 66 507.433339 $41264.4800 $81.3200
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 5 5 33.571429 $2186.1800 $65.1200
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 2 2 27.428571 $1786.1500 $65.1200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 1.714286 $139.4100 $81.3200
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 7.714286 $627.3300 $81.3200
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Subtotal (Total Children Is Unduplicated) 544 1318 6250.361569 $359665.3700 $57.5400
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Total 1599 6539.737758 $374150.4000 $57.2100
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Number of Children (Unduplicated) With at Least One Authorization 568