Summary Report for FSPSAs Initiated During the Report Period Center: 10
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 3190 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 7 7 4.361112 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 7 7 4.361112 $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 334 335 352.743248 $7569.8700 $21.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 332 333 350.743248 $5664.5000 $16.1500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 331 332 349.743248 $2769.9700 $7.9200
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 1.000000 $10.8800 $10.8800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 330 331 348.743248 $11093.5200 $31.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 331 332 349.743248 $8093.0600 $23.1400
NUTR -97802 NUTRITIONAL EVAL, INITIAL 5 6 2.122222 $106.1100 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 20 20 17.911111 $1040.8100 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 3 3 3.000000 $174.3300 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 5 7 8.000000 $464.8800 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 28 29 28.322222 $1645.8000 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 7 8 8.000000 $464.8800 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $58.1100 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 12 14 120.452381 $6999.4900 $58.1100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 2 2 19.285715 $1120.6900 $58.1100
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Subtotal (Total Children Is Unduplicated) 388 1756 1962.809891 $47350.2100 $24.1200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 6 6.000000 $30000.0000 $5000.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 91 115 195.255556 $9762.7800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 15 16 18.166668 $908.3400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 13 13 13.700000 $685.0000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 60 63 79.799998 $3989.9900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 634 763 5094.189730 $275086.1800 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 7.571429 $408.8600 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 106 113 729.760718 $59344.1200 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 165 176 914.554761 $74371.5200 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 145 161 918.500006 $74692.3700 $81.3200
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Subtotal (Total Children Is Unduplicated) 838 1427 7977.498866 $529249.1600 $66.3400
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Total 3190 9944.669869 $576599.3700 $57.9800
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Number of Children (Unduplicated) With at Least One Authorization 863