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: 10-01-25 and 12-31-25 Date of Report: 01-07-26 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 3434 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 4 4 1.988889 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 4 4 1.988889 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 370 370 367.553425 $7887.7000 $21.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 368 368 365.553425 $5903.6900 $16.1500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 366 366 363.553425 $2879.3400 $7.9200
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 1.000000 $10.8800 $10.8800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 365 365 362.553425 $11532.8200 $31.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 366 366 363.553425 $8412.6300 $23.1400
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.000000 $90.6400 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.000000 $231.6200 $115.8100
NUTR -97802 NUTRITIONAL EVAL, INITIAL 11 12 17.199999 $860.0000 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 15 16 15.611111 $907.1600 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 8 8 8.000000 $464.8800 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 4 4 4.000000 $232.4400 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 4 4 3.785714 $219.9900 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 14 15 15.000000 $871.6500 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 16 16 16.000000 $929.7600 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 18 19 125.319046 $7282.2900 $58.1100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 2 2 7.000000 $406.7700 $58.1100
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Subtotal (Total Children Is Unduplicated) 422 1936 2039.682995 $49124.2500 $24.0800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 4.000000 $20000.0000 $5000.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 111 132 184.523412 $9226.1600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 27 28 31.611110 $1580.5500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 15 16 9.144445 $457.2300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 67 68 90.633331 $4531.6600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 702 763 4919.555133 $265656.0600 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 115 124 647.620644 $52664.5300 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 165 178 779.865890 $63418.7400 $81.3200
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 1.000000 $229.6100 $229.6100
SENS -V5264 EARMOLD 1 1 1.000000 $18.1300 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 167 179 1012.692076 $82352.1300 $81.3200
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Subtotal (Total Children Is Unduplicated) 895 1494 7681.646041 $500134.7900 $65.1100
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Total 3434 9723.317925 $549259.0400 $56.4900
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Number of Children (Unduplicated) With at Least One Authorization 928