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: 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 2956 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 3 3 1.333334 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 1.333334 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 1.000000 $15.1900 $15.1900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 268 272 272.000000 $5837.1200 $21.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 266 268 268.000000 $4328.2000 $16.1500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 267 269 269.000000 $2130.4800 $7.9200
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 266 268 268.000000 $8525.0800 $31.8100
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.000000 $15.1900 $15.1900
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 262 264 264.000000 $6108.9600 $23.1400
AUDE -92650 AEP SCR AUDITORY POTENTIAL 1 1 1.000000 $54.9000 $54.9000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 5 5 5.733334 $286.6700 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 16 16 15.200000 $883.2700 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 6 7 7.000000 $406.7700 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 32 34 34.000000 $1975.7400 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 3.000000 $174.3300 $58.1100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $58.1100 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $58.1100 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 7 8 41.142857 $2390.8100 $58.1100
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Subtotal (Total Children Is Unduplicated) 324 1423 1456.076191 $33481.3700 $22.9900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 6 6.000000 $30000.0000 $5000.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 124 147 161.058732 $8052.9500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 24 26 26.988891 $1349.4600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 27 29 22.866664 $1143.3200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 73 77 93.677779 $4683.9000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 686 773 4469.007900 $241326.4900 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 115 125 705.035711 $57333.5300 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 159 170 791.857148 $64393.8600 $81.3200
SENS -V5264 EARMOLD 1 1 1.000000 $18.1300 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 157 174 919.111902 $74742.2300 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 2 2 1.285714 $104.5600 $81.3300
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Subtotal (Total Children Is Unduplicated) 871 1530 7197.890441 $483148.4100 $67.1200
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Total 2956 8655.299966 $516629.7800 $59.6900
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Number of Children (Unduplicated) With at Least One Authorization 911