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: 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 4178 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 2 2 0.733334 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 0.733334 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 1.000000 $15.1900 $15.1900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 288 294 294.000000 $6309.2400 $21.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 243 249 249.000000 $4021.3500 $16.1500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 243 249 249.000000 $1972.0800 $7.9200
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 242 248 248.000000 $7888.8800 $31.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 243 249 248.122222 $5741.5500 $23.1400
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 3.000000 $135.9600 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.000000 $231.6200 $115.8100
NUTR -97802 NUTRITIONAL EVAL, INITIAL 6 6 5.600000 $280.0000 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 65 79 79.000000 $4590.6900 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 21 22 21.455556 $1246.7800 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 89 99 96.744445 $5621.8200 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $58.1100 $58.1100
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Subtotal (Total Children Is Unduplicated) 422 1502 1497.922223 $38113.2800 $25.4400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 11 13 15.428571 $77143.0000 $5000.0100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 2 2.000000 $100.0000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 213 254 254.890469 $12744.5000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 30 37 35.466667 $1773.3400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 55 61 48.611108 $2430.5400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 164 183 187.525395 $9376.2700 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 2 2 5.857143 $292.8600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 891 1002 6027.417052 $325480.5300 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 267 321 1840.407944 $149661.9500 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 303 358 1653.921424 $134496.9300 $81.3200
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 1.000000 $114.8100 $114.8100
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 2.000000 $459.2200 $229.6100
SENS -V5264 EARMOLD 2 2 2.000000 $36.2600 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 358 436 2428.361900 $197474.4000 $81.3200
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Subtotal (Total Children Is Unduplicated) 1379 2674 12504.887673 $911584.5900 $72.9000
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Total 4178 14003.543230 $949697.8700 $67.8200
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Number of Children (Unduplicated) With at Least One Authorization 1498