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 966 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 7 7 3.661112 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 7 7 3.661112 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 25 25 25.000000 $536.5000 $21.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 24 24 24.000000 $387.6000 $16.1500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 24 24 24.000000 $190.0800 $7.9200
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 23 23 23.000000 $731.6300 $31.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 23 23 23.000000 $532.2200 $23.1400
NUTR -97802 NUTRITIONAL EVAL, INITIAL 9 10 6.533333 $326.6700 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 5 5 5.000000 $290.5500 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 5 5 5.000000 $290.5500 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 2 2 12.880953 $748.5100 $58.1100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 1 8.714286 $506.3900 $58.1100
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Subtotal (Total Children Is Unduplicated) 48 149 164.128572 $4947.4700 $30.1400
EI Services, Class # 03
CONIF -CONIF CONSULT, ITDS FACE TO FACE 139 167 266.212698 $13310.6400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 28 29 37.866669 $1893.3500 $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 336 405 2569.005577 $138726.2400 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 16 17 102.607143 $8344.0000 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 24 24 125.678572 $10220.1800 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 44 45 299.928570 $24390.1900 $81.3200
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Subtotal (Total Children Is Unduplicated) 489 810 3558.602402 $204749.7600 $57.5400
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Total 966 3726.392086 $209697.2300 $56.2700
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Number of Children (Unduplicated) With at Least One Authorization 500