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 389 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 6 6 3.361112 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 6 6 3.361112 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 14 14 14.000000 $300.4400 $21.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 13 13 13.000000 $209.9500 $16.1500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 13 13 13.000000 $102.9600 $7.9200
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 13 13 13.000000 $413.5300 $31.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 13 13 13.000000 $300.8200 $23.1400
NUTR -97802 NUTRITIONAL EVAL, INITIAL 5 6 2.122222 $106.1100 $50.0000
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 2.000000 $116.2200 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $58.1100 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 2 2 12.880953 $748.5100 $58.1100
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Subtotal (Total Children Is Unduplicated) 24 78 85.003175 $2414.7600 $28.4100
EI Services, Class # 03
CONIF -CONIF CONSULT, ITDS FACE TO FACE 90 114 193.622223 $9681.1200 $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 57 62 417.475400 $22543.6600 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 6 7 58.785715 $4780.4500 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 12 12 65.857143 $5355.5100 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 17 18 137.142856 $11152.4500 $81.3200
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Subtotal (Total Children Is Unduplicated) 173 305 984.550003 $59096.5100 $60.0200
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Total 389 1072.914290 $61511.2800 $57.3300
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Number of Children (Unduplicated) With at Least One Authorization 179