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: 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 4784 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 9 9 4.961112 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 9 9 4.961112 $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 480 482 496.893932 $10663.3400 $21.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 478 480 494.893932 $7992.5400 $16.1500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 477 479 493.893932 $3911.6400 $7.9200
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 1.000000 $10.8800 $10.8800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 476 478 492.893932 $15678.9500 $31.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 477 479 493.893932 $11428.7000 $23.1400
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.3200 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.000000 $231.6200 $115.8100
NUTR -97802 NUTRITIONAL EVAL, INITIAL 9 10 6.533333 $326.6700 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 40 41 38.911111 $2261.1200 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 8 8 8.000000 $464.8800 $58.1100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 9 11 12.000000 $697.3200 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 4 4 4.000000 $232.4400 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 50 52 52.179365 $3032.1400 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 15 17 16.100000 $935.5700 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $58.1100 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 18 20 173.595239 $10087.6200 $58.1100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 4 4 29.000001 $1685.1900 $58.1100
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Subtotal (Total Children Is Unduplicated) 589 2571 2819.788709 $69817.3600 $24.7600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 10 12 12.000000 $60000.0000 $5000.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 140 168 267.846031 $13392.3100 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 29 30 39.966669 $1998.3500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 19 19 18.755555 $937.7800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 98 103 128.833332 $6441.6600 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 9.714286 $485.7200 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 920 1116 7277.889351 $393005.9200 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 7.571429 $408.8600 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 177 187 1206.510718 $98113.4000 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 247 263 1345.804764 $109440.7100 $81.3200
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 2.000000 $459.2200 $229.6100
SENS -V5264 EARMOLD 1 1 2.000000 $36.2600 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 280 302 1772.964300 $144177.3600 $81.3200
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Subtotal (Total Children Is Unduplicated) 1279 2204 12091.856435 $828897.5300 $68.5500
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Total 4784 14916.606256 $898714.8900 $60.2500
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Number of Children (Unduplicated) With at Least One Authorization 1318