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: 01-01-25 and 03-31-25 Date of Report: 04-06-25 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 655 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 0.566667 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 0.566667 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 13 13 13.000000 $278.9800 $21.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 12 12 12.000000 $193.8000 $16.1500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 12 12 12.000000 $95.0400 $7.9200
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 12 12 12.000000 $381.7200 $31.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 12 12 12.000000 $277.6800 $23.1400
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.3200 $45.3200
NUTR -97802 NUTRITIONAL EVAL, INITIAL 4 4 7.233333 $361.6700 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 7 8 8.000000 $464.8800 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 10 11 11.000000 $639.2100 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 12.857143 $747.1300 $58.1100
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Subtotal (Total Children Is Unduplicated) 34 88 102.090476 $3543.5300 $34.7100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.000000 $10000.0000 $5000.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 96 110 158.352380 $7917.6200 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 27 28 43.353967 $2167.7000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 17 19 21.150795 $1057.5500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 60 63 78.488888 $3924.4400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 202 239 1383.782546 $74724.2600 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 30 31 193.285715 $15717.9800 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 25 30 116.845239 $9501.8400 $81.3200
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 1.000000 $114.8100 $114.8100
SENS -V5264 EARMOLD 1 1 1.000000 $18.1300 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 39 41 271.607146 $22087.1100 $81.3200
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Subtotal (Total Children Is Unduplicated) 339 565 2270.866676 $147231.4300 $64.8300
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Total 655 2373.523819 $150774.9600 $63.5200
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Number of Children (Unduplicated) With at Least One Authorization 345