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 742 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
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 0.700000 $10.6300 $15.1900
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.866667 $6.8600 $7.9200
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.588889 $18.7300 $31.8100
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.633333 $9.6200 $15.1900
OCTH -97165 OT EVAL LOW COMPLEXITY 4 4 2.183333 $126.8700 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 1.000000 $58.1100 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 4 4 2.472223 $143.6700 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 1.000000 $58.1100 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $58.1100 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 5.714286 $332.0600 $58.1100
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Subtotal (Total Children Is Unduplicated) 14 17 17.158731 $880.8800 $51.3400
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 29 29 228.347621 $12330.7700 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 2 2 14.000000 $756.0000 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 10.142857 $824.8200 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 1 1 4.000000 $260.4800 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 3 3 15.857143 $1289.5100 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 7 7 65.428572 $5320.6500 $81.3200
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 3.714286 $241.8800 $65.1200
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 1 1 2.000000 $130.2400 $65.1200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 1.714286 $139.4100 $81.3200
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Subtotal (Total Children Is Unduplicated) 287 705 1590.694859 $82923.7300 $52.1300
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Total 742 1621.936924 $83804.6200 $51.6700
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Number of Children (Unduplicated) With at Least One Authorization 307