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: 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 2292 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 5 5 1.500000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 5 5 1.500000 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 201 203 203.000000 $4356.3800 $21.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 200 202 202.000000 $3262.3000 $16.1500
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.000000 $24.2800 $24.2800
AUDE -92558 OTOACOUSTIC EMISSIONS (SCREENING) 22 22 22.000000 $151.1400 $6.8700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 179 181 181.000000 $1433.5200 $7.9200
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 22 22 22.000000 $239.3600 $10.8800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 178 180 180.000000 $5725.8000 $31.8100
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 22 22 22.000000 $334.1800 $15.1900
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 178 180 180.000000 $4165.2000 $23.1400
NUTR -97802 NUTRITIONAL EVAL, INITIAL 7 7 12.290477 $614.5300 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 13 13 13.000000 $755.4300 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 18 18 18.000000 $1045.9800 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 4 4 4.000000 $232.4400 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 16 17 17.000000 $987.8700 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 15 15 15.000000 $871.6500 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 19 20 119.857141 $6964.9100 $58.1100
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Subtotal (Total Children Is Unduplicated) 268 1108 1213.147618 $31223.0700 $25.7400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.000000 $15000.0000 $5000.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 83 97 146.673019 $7333.6700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 18 20 25.433332 $1271.6600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 8 8 14.463492 $723.1800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 58 60 75.334922 $3766.7500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 517 591 4559.427760 $246209.1800 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 96 105 760.000001 $61803.1900 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 142 150 769.864289 $62605.3700 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 136 145 963.285714 $78334.4400 $81.3200
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Subtotal (Total Children Is Unduplicated) 703 1179 7317.482529 $477047.4400 $65.1900
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Total 2292 8532.130147 $508270.5100 $59.5700
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Number of Children (Unduplicated) With at Least One Authorization 722