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: 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 1657 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 14 14 7.105555 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 14 14 7.105555 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 13 13 5.644443 $348.3100 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 30 31 24.215873 $367.8400 $15.1900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 12 12 4.955556 $106.3500 $21.4600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.711111 $18.5200 $26.0400
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 4 4 2.211111 $53.6900 $24.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 0.055555 $0.4400 $7.9100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 6 6 8.233333 $261.9000 $31.8100
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 21 21 12.561111 $190.8000 $15.1900
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 25 26 19.777779 $457.6600 $23.1400
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 4 4 6.011111 $360.1900 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 11 11 22.000000 $1318.2400 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 4 4 6.011111 $486.7800 $80.9800
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 11 11 22.000000 $1781.5600 $80.9800
OCTF -97168 OT RE-EVAL EST PLAN CARE 5 7 7.000000 $406.7700 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 21 21 11.172222 $649.2200 $58.1100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 0.472222 $27.4400 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 3 4 2.655555 $154.3100 $58.1100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 0.005556 $0.3300 $58.5700
OCTH -97167 OT EVAL HIGH COMPLEXITY 10 11 6.944446 $403.5500 $58.1100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 0.422222 $24.5300 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 4 4 2.644444 $153.6700 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 12 13 6.733333 $391.2700 $58.1100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 0.944444 $54.8800 $58.1100
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 1 1 0.238889 $13.8800 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 9 9 6.750000 $392.2400 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 32 35 19.738888 $1147.0200 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 2 2 0.183333 $10.6500 $58.1000
SPCH -92522 EVAL OF SPCH SOUND PROD 4 4 4.744445 $275.7000 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 31 32 20.411111 $1186.0900 $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 8 8 6.766667 $393.2100 $58.1100
SPCH -92610TLGT EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $58.1100 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 6 6 76.571428 $4449.5700 $58.1100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 1 6.142857 $356.9600 $58.1100
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Subtotal (Total Children Is Unduplicated) 217 310 316.930156 $16359.7900 $51.6200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 2 2.000000 $10000.0000 $5000.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 2 2 0.511111 $35.4400 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 2.000000 $463.2400 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 92 128 109.420443 $5471.0600 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 17 21 19.500000 $975.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 6 6 5.805556 $145.1400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 203 236 525.923801 $26296.1500 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 3 3 7.533334 $376.6700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 81 97 242.885710 $12144.2700 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 4 6 8.433333 $421.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.066667 $1.6700 $25.0100
CONPF -CONPF CONSULT, PT, FACE TO FACE 40 43 80.466664 $4023.3200 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 4 4 5.300000 $265.0000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 90 101 190.804765 $9540.2500 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 3 4 7.599999 $380.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 456 502 3888.633364 $209986.2100 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 44 47 326.304762 $17620.4600 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 22 25 204.428571 $16624.1300 $81.3200
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 22.714286 $1847.1300 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 9 9 65.000002 $4232.7900 $65.1200
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 9.714286 $632.6000 $65.1200
OCCT -97530TLGTHM OT SESSION BY OT ASST 1 1 12.142857 $790.7500 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 18 19 163.571431 $13301.6100 $81.3200
PHY -97110HM PT SESSION BY PT ASST 3 3 2.066667 $134.5800 $65.1200
PHY -97110TLGT PT SESSION BY LICENSED PT 1 1 6.142857 $499.5400 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 54 60 450.571433 $36640.4800 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 2 11.571429 $940.9900 $81.3200
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 4.571429 $297.6900 $65.1200
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 2 2 3.857143 $251.1700 $65.1200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 2 2 22.571428 $1835.5100 $81.3200
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 6.142857 $499.5400 $81.3200
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Subtotal (Total Children Is Unduplicated) 552 1333 6408.256185 $376674.0700 $58.7800
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Total 1657 6732.291896 $393033.8500 $58.3800
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Number of Children (Unduplicated) With at Least One Authorization 579