Summary Report for FSPSAs Ending During the Report Period Center: 10
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 478 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 2 2 1.211112 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 1.211112 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 18 18 18.000000 $386.2800 $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 7.233334 $361.6700 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 4 4 4.000000 $232.4400 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.211111 $12.2700 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 5 5 5.000000 $290.5500 $58.1100
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Subtotal (Total Children Is Unduplicated) 31 101 102.444445 $2626.5500 $25.6400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 107 119 108.726983 $5436.3400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 16 20 20.322224 $1016.1200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 22 22 17.400000 $870.0000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 76 82 78.100002 $3905.0100 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 76 84 484.466667 $26161.2100 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 13 13 77.892858 $6334.2300 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 11 13 122.221428 $9939.0500 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 19 21 151.500001 $12319.9600 $81.3200
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Subtotal (Total Children Is Unduplicated) 192 375 1061.630163 $70981.9200 $66.8600
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Total 478 1165.285720 $73608.4700 $63.1700
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Number of Children (Unduplicated) With at Least One Authorization 203