Summary Report for FSPSAs Initiated During the Report Period Center: 09
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: 07-01-24 and 09-30-24 Date of Report: 04-06-25 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2626 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 29 29 37.406352 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 29 29 37.406352 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 2 2 1.555556 $33.3800 $21.4600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 1.555556 $40.5100 $26.0400
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 1.555556 $25.1200 $16.1500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 1.555556 $12.3200 $7.9200
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 1.555556 $49.4800 $31.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 1.555556 $36.0000 $23.1400
AUDE -92651 AEP HEARING STATUS DETER I&R 2 2 1.555556 $121.7300 $78.2500
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.555556 $25.1800 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.555556 $64.3400 $115.8200
NUTR -97802 NUTRITIONAL EVAL, INITIAL 6 6 16.571428 $828.5800 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 19 21 115.838097 $5791.9000 $50.0000
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 2.000000 $116.2200 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 28 35 216.428574 $12576.6800 $58.1100
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Subtotal (Total Children Is Unduplicated) 53 79 362.838103 $19721.4400 $54.3500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 2.850000 $14250.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 223 351 471.600665 $23580.0500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 93 111 106.516520 $2662.9200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 157 167 127.800000 $6390.0000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.000000 $25.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 88 92 72.261112 $3613.0600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.000000 $25.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 49 50 39.394444 $1969.7200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 102 105 90.105555 $4505.2800 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 0.428571 $21.4300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 960 1125 7085.328646 $382607.8000 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 111 120 649.622232 $52827.3200 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 14 15 99.714288 $6493.4000 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 146 162 1030.284140 $83782.7200 $81.3200
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.555556 $127.5700 $229.6300
SENS -V5264 EARMOLD 2 2 1.555556 $28.2000 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 196 210 1366.130972 $111093.7500 $81.3200
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Subtotal (Total Children Is Unduplicated) 1145 2518 11146.148257 $694003.2100 $62.2600
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Total 2626 11546.392712 $713724.6500 $61.8100
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Number of Children (Unduplicated) With at Least One Authorization 1170