Summary Report for FSPSAs Ending During the Report Period Center: 07
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: 04-01-25 and 06-30-25 Date of Report: 07-19-25 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1795 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 19 20 15.248414 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 19 20 15.248414 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.244444 $15.0800 $61.7000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 7 7 5.088888 $77.3000 $15.1900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 5 5 2.738889 $58.7800 $21.4600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 9.301587 $242.2100 $26.0400
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 6.857143 $110.7400 $16.1500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 6.857143 $54.3100 $7.9200
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 3 3 8.668254 $275.7400 $31.8100
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 12 12 7.800000 $118.4800 $15.1900
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 3 3 2.205556 $51.0400 $23.1400
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $119.8400 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 3 3 6.000000 $359.5200 $59.9200
OCTF -97168 OT RE-EVAL EST PLAN CARE 8 9 9.000000 $522.9900 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 6 6 2.861111 $166.2600 $58.1100
OCTH -97165GT OT EVAL LOW COMPLEXITY 2 2 0.583334 $33.9000 $58.1200
OCTH -97165TL OT EVAL LOW COMPLEXITY 1 1 0.766667 $44.5500 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 4 4 2.650000 $153.9900 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 5 5 4.311111 $250.5200 $58.1100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 1.000000 $58.1100 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 7 8 2.794444 $162.3800 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 1.766667 $102.6600 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 22 23 16.088888 $934.9200 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 2 2 1.122222 $65.2100 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 12 12 10.622223 $617.2600 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 1.566667 $91.0400 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 3 5 13.052381 $758.4700 $58.1100
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Subtotal (Total Children Is Unduplicated) 92 123 126.947619 $5503.4200 $43.3500
EI Services, Class # 03
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 11.571429 $802.4800 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 5.000000 $1158.1000 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 175 241 197.443862 $9872.2700 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 31 37 34.005556 $1700.2800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 14 16 13.555556 $338.8900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 374 433 1059.488892 $52974.4700 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 6 6 14.166668 $708.3400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 2 2.833333 $70.8300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 177 196 416.300003 $20815.0100 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 8 8 10.333334 $516.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 1.666667 $41.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 82 84 182.946029 $9147.2900 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 3 3 5.300000 $265.0000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 209 230 435.793653 $21789.6900 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 5 6 12.733333 $636.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.500000 $12.5000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 290 308 2461.109515 $132899.9100 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 2.142857 $115.7200 $54.0000
INTR -T1013 INTERPRETER 1 1 10.571429 $528.5700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 18 19 127.714284 $10385.7200 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 1 1 9.285714 $604.6800 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 15 15 79.999999 $6505.5900 $81.3200
PHY -97110HM PT SESSION BY PT ASST 1 1 7.714286 $502.3600 $65.1200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 30 33 242.714283 $19737.5200 $81.3200
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 3 3 15.714285 $1023.3200 $65.1200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 12.857143 $1045.5400 $81.3200
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Subtotal (Total Children Is Unduplicated) 613 1652 5373.462110 $294199.0700 $54.7500
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Total 1795 5515.658143 $299702.4900 $54.3400
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Number of Children (Unduplicated) With at Least One Authorization 640