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: 04-01-25 and 06-30-25 Date of Report: 07-19-25 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 770 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 13 13 7.161112 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 13 13 7.161112 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.244444 $15.0800 $61.7000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 2 2 2.000000 $30.3800 $15.1900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 1.811111 $57.6100 $31.8100
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.011111 $0.1700 $15.1700
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.205556 $4.7600 $23.1500
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 2 2.000000 $116.2200 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.350000 $20.3400 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 2.000000 $116.2200 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 2 2 1.122222 $65.2100 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 2.166667 $125.9100 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.388889 $22.6000 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 5.000000 $290.5500 $58.1100
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Subtotal (Total Children Is Unduplicated) 17 21 19.300000 $981.2600 $50.8400
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 91 123 101.475999 $5073.8400 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 17 21 19.500000 $975.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 7 9 9.305556 $232.6400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 219 257 607.036504 $30351.8100 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 2 2 3.633334 $181.6700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 95 106 219.361908 $10968.1100 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 4 4 5.233334 $261.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.066667 $1.6700 $25.0100
CONPF -CONPF CONSULT, PT, FACE TO FACE 35 36 77.509521 $3875.4700 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 1 1 3.033333 $151.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 119 125 202.888889 $10144.4500 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 2 3 5.899999 $295.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 32 34 267.942857 $14468.9200 $54.0000
INTR -T1013 INTERPRETER 1 1 10.571429 $528.5700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 3 4 17.000000 $1382.4400 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 2 2 13.142857 $1068.7800 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 4 4 24.857142 $2021.3900 $81.3200
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 8.000000 $520.9600 $65.1200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 12.857143 $1045.5400 $81.3200
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Subtotal (Total Children Is Unduplicated) 301 736 1611.316472 $84012.8100 $52.1400
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Total 770 1637.777584 $84994.0800 $51.9000
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Number of Children (Unduplicated) With at Least One Authorization 317