Summary Report for FSPSAs Initiated During the Report Period Center: 07
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: 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 1673 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 17 17 8.005555 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 17 17 8.005555 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 0.705555 $43.5400 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 3 3 1.355555 $20.5900 $15.1900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 11 11 6.638891 $142.4800 $21.4600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.061111 $1.5900 $26.0300
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 3 3 1.577778 $38.3100 $24.2800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 6.142857 $195.4100 $31.8100
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 14 14 4.977779 $75.6100 $15.1900
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 3 4 1.322223 $30.6000 $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 5 5 5.000000 $290.5500 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 6 6 2.922223 $169.8100 $58.1100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 0.150000 $8.7200 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 5 5 2.872222 $166.9000 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 4 4 3.194444 $185.6300 $58.1100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 1.000000 $58.1100 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 8 9 2.427778 $141.0800 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 11 11 6.122221 $355.7600 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 0.122222 $7.1000 $58.1000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 5 6 3.533334 $205.3300 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 4 4 2.805556 $163.0300 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 5 6 36.623811 $2128.2100 $58.1100
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Subtotal (Total Children Is Unduplicated) 81 103 98.555560 $4965.8200 $50.3900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.288889 $20.0400 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 5.000000 $1158.1000 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 175 245 196.193860 $9809.7600 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 32 38 35.505556 $1775.2800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 15 15 12.522223 $313.0600 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 342 399 919.456339 $45972.7700 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 7 7 10.333335 $516.6800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 3 3 7.366667 $184.1700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 155 183 410.730152 $20536.4800 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 7 9 10.100000 $505.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.066667 $1.6700 $25.0100
CONPF -CONPF CONSULT, PT, FACE TO FACE 78 84 168.099997 $8404.9900 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 9 9 20.933332 $1046.6600 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.466667 $11.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 158 176 353.119053 $17655.9800 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 7 8 14.066666 $703.3300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.500000 $12.5000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 286 302 2351.104777 $126959.6600 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 13.000000 $702.0000 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 19 19 131.857143 $10722.6400 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 15 16 153.085715 $12448.9500 $81.3200
PHY -97110HM PT SESSION BY PT ASST 1 1 18.285714 $1190.7600 $65.1200
SENS -V5264 EARMOLD 1 1 0.577778 $10.4800 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 23 26 184.095240 $14970.6400 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 12.000000 $975.8400 $81.3200
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 8.142857 $530.2700 $65.1200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 11.428571 $929.3700 $81.3200
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Subtotal (Total Children Is Unduplicated) 615 1553 5049.327198 $283068.7100 $56.0600
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Total 1673 5155.888313 $288034.5300 $55.8700
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Number of Children (Unduplicated) With at Least One Authorization 638