Summary Report for FSPSAs Ending During the Report Period Center: 09
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 2668 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 31 32 41.646032 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 31 32 41.646032 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 1.000000 $21.4600 $21.4600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.000000 $26.0400 $26.0400
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.000000 $16.1500 $16.1500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.000000 $7.9200 $7.9200
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.000000 $31.8100 $31.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.000000 $23.1400 $23.1400
AUDE -92651 AEP HEARING STATUS DETER I&R 1 1 1.000000 $78.2500 $78.2500
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.8100 $115.8100
NUTR -97802 NUTRITIONAL EVAL, INITIAL 11 12 27.123810 $1356.1900 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 22 22 98.038096 $4901.9100 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 8.142857 $473.1800 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 2.000000 $116.2200 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $58.1100 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 3 3.571428 $207.5300 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 29 34 314.857142 $18296.3500 $58.1100
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Subtotal (Total Children Is Unduplicated) 64 85 463.733333 $25788.1800 $55.6100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 254 405 532.842508 $26642.1200 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 101 125 131.241685 $3281.0400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 164 178 142.420634 $7121.0300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.000000 $25.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 100 104 95.605557 $4780.2900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 3 2.083333 $52.0800 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 60 64 54.416667 $2720.8400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 2.000000 $50.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 99 106 95.644988 $4782.2600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 2.000000 $50.0000 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 11.142857 $557.1500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 892 1022 6584.752318 $355576.6600 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 111 125 757.396824 $61591.5000 $81.3200
OCCT -97530GO OT SESSION BY LICENSED OT 1 1 8.142857 $662.1800 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 10 11 55.938095 $3642.6900 $65.1200
OCCT -97530TLGTHM OT SESSION BY OT ASST 1 1 6.142857 $400.0300 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 141 159 1065.111898 $86614.9000 $81.3200
PHY -97110HM PT SESSION BY PT ASST 2 2 14.428571 $939.5900 $65.1200
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 1.000000 $229.6100 $229.6100
SENS -V5264 EARMOLD 1 1 1.000000 $18.1300 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 208 236 1505.409511 $122419.9100 $81.3200
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Subtotal (Total Children Is Unduplicated) 1095 2551 11070.721160 $687156.9800 $62.0700
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Total 2668 11576.100525 $712945.1600 $61.5900
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Number of Children (Unduplicated) With at Least One Authorization 1127