Summary Report for FSPSAs Ending During the Report Period Center: 52
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 1135 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 5 6 2.022223 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 5 6 2.022223 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 2.100000 $129.5900 $61.7100
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 2.100000 $33.9200 $16.1500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 2.100000 $16.6300 $7.9200
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 2.100000 $66.8000 $31.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 2.100000 $48.5900 $23.1400
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.345205 $106.2800 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.345205 $39.9800 $115.8100
OCTH -97165 OT EVAL LOW COMPLEXITY 11 11 11.000000 $639.2100 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 5 5 5.000000 $290.5500 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 6 6 9.200000 $534.6100 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 4 4 4.000000 $232.4400 $58.1100
SCREEN-T1023 SCREENING 26 26 26.000000 $1403.4800 $53.9800
SPCH -92521 EVAL OF SPEECH FLUENCY 9 9 9.333333 $542.3600 $58.1100
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 1.000000 $58.1100 $58.1100
SPCH -92523 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 15 15 32.323810 $1878.3400 $58.1100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 1 9.285714 $539.5900 $58.1100
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Subtotal (Total Children Is Unduplicated) 73 89 123.333267 $6734.8100 $54.6100
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $231.6200 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 2 4.033333 $201.6700 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 209 256 586.816660 $29340.8000 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 1 1 1.000000 $50.0000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.400000 $35.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 84 89 237.433325 $11871.6300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.300000 $7.5000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 55 66 192.066665 $9603.3300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 103 110 258.766663 $12938.3200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 7 7 23.733332 $593.3300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 321 350 1464.914277 $79105.3900 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 11.000000 $594.0000 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 31 32 131.047620 $10656.8100 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 2 2 11.428571 $744.2300 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 46 49 144.457142 $11747.2800 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 1 1 2.533333 $206.0100 $81.3200
PHY -97110HM PT SESSION BY PT ASST 8 8 20.304763 $1322.2500 $65.1200
PHY -97110HMGT PT SESSION BY PT ASST 1 1 10.857143 $707.0100 $65.1200
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 1.000000 $459.2200 $459.2200
SENS -V5264 EARMOLD 1 1 1.400000 $25.3800 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 57 60 204.030954 $16591.7900 $81.3200
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Subtotal (Total Children Is Unduplicated) 417 1040 3309.523781 $187032.5500 $56.5100
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Total 1135 3434.879271 $193767.3700 $56.4100
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Number of Children (Unduplicated) With at Least One Authorization 441