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 473 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 0.988889 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 0.988889 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 17 17 17.000000 $364.8200 $21.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 16 16 16.000000 $258.4000 $16.1500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 16 16 16.000000 $126.7200 $7.9200
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 16 16 16.000000 $508.9600 $31.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 16 16 16.000000 $370.2400 $23.1400
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.3200 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.8100 $115.8100
NUTR -97802 NUTRITIONAL EVAL, INITIAL 11 11 16.199999 $810.0000 $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 4 4 19.271429 $1119.8600 $58.1100
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Subtotal (Total Children Is Unduplicated) 34 102 122.471428 $3952.5700 $32.2700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 110 131 183.865079 $9193.2500 $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 66 74 457.580954 $24709.3600 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 7 10 51.357142 $4176.3600 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 14 17 77.864287 $6331.9200 $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 18 21 139.928573 $11378.9800 $81.3200
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Subtotal (Total Children Is Unduplicated) 197 368 1044.984921 $67607.0300 $64.7000
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Total 473 1168.445238 $71559.6000 $61.2400
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Number of Children (Unduplicated) With at Least One Authorization 204