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 718 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
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 1.000000 $15.1900 $15.1900
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.277778 $4.2200 $15.1900
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 3 4 1.322223 $30.6000 $23.1400
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 1.000000 $58.1100 $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 1.072222 $62.3100 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 0.122222 $7.1000 $58.1000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 3 2.166667 $125.9100 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 1.388889 $80.7100 $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) 13 18 15.350001 $790.9100 $51.5300
EI Services, Class # 03
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 22 24 214.123812 $11562.7000 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 13.000000 $702.0000 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 4 4 45.857142 $3729.1100 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 2 2 32.857143 $2671.9400 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 4 18.000000 $1463.7700 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 11.428571 $929.3700 $81.3200
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Subtotal (Total Children Is Unduplicated) 286 686 1539.006940 $81099.0800 $52.7000
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Total 718 1561.462496 $81889.9900 $52.4400
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Number of Children (Unduplicated) With at Least One Authorization 301