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: 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 4584 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 3 3 1.333334 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 1.333334 $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 406 410 410.000000 $8798.6000 $21.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 402 404 404.000000 $6524.6000 $16.1500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 403 405 405.000000 $3207.6000 $7.9200
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 403 405 405.000000 $12883.0500 $31.8100
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.000000 $15.1900 $15.1900
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 399 401 401.000000 $9279.1400 $23.1400
AUDE -92650 AEP SCR AUDITORY POTENTIAL 1 1 1.000000 $54.9000 $54.9000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.3200 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.8100 $115.8100
NUTR -97802 NUTRITIONAL EVAL, INITIAL 9 9 11.955556 $597.7800 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 38 40 53.057143 $3083.1500 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 5 5 5.000000 $290.5500 $58.1100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 8 10 10.000000 $581.1000 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 69 72 72.857143 $4233.7300 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 12 13 16.853968 $979.3900 $58.1100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 2.000000 $116.2200 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $58.1100 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 8 9 47.571428 $2764.3700 $58.1100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 1 1.000000 $58.1100 $58.1100
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Subtotal (Total Children Is Unduplicated) 516 2196 2255.295238 $53934.3400 $23.9100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 9 10 10.000000 $50000.0000 $5000.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 175 206 230.825394 $11541.2600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 42 47 55.817462 $2790.8900 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 32 34 25.911108 $1295.5400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 115 125 133.688887 $6684.4400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1007 1143 6453.111063 $348468.0900 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 193 211 1166.170632 $94833.0400 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 254 272 1254.338106 $102002.8700 $81.3200
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 1.000000 $114.8100 $114.8100
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 1.000000 $229.6100 $229.6100
SENS -V5264 EARMOLD 3 3 3.000000 $54.3900 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 298 329 1667.426189 $135595.1600 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 3 3 7.357143 $598.2900 $81.3200
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Subtotal (Total Children Is Unduplicated) 1341 2385 11009.645984 $754208.3700 $68.5000
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Total 4584 13266.274556 $808142.7100 $60.9200
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Number of Children (Unduplicated) With at Least One Authorization 1407