Summary Report for FSPSAs Ending During the Report Period Center: 54
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 1721 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 12 12 11.544444 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 12 12 11.544444 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AACIS -92597 AAC INTIAL EVAL BY LICENSED SLP 3 3 2.400000 $280.3900 $116.8300
AACIS -92597TL AAC INTIAL EVAL BY LICENSED SLP 1 1 0.316667 $37.0000 $116.8400
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 58 69 50.998411 $2473.4200 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 13 13 8.305555 $512.5300 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 1.000000 $15.1900 $15.1900
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) 2 2 2.000000 $32.3000 $16.1500
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 29 29 21.811112 $529.5800 $24.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 2.000000 $15.8400 $7.9200
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 4 4 2.805555 $89.2400 $31.8100
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 2 2.000000 $99.1800 $49.5900
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 2.000000 $30.3800 $15.1900
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 2.000000 $46.2800 $23.1400
AUDE -V5010 ASSESSMENT FOR HEARING AID 19 19 9.527778 $431.8000 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 1.777778 $205.8900 $115.8100
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 0.138889 $8.0700 $58.1100
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 112 155 111.081745 $4854.5900 $43.7000
EI Services, Class # 03
AACFIT-92609 AAC FITTING, ADJUST, TRAINING VISIT 5 5 3.161112 $151.5500 $47.9400
AACFIT-92609TL AAC FITTING, ADJUST, TRAINING VISIT 1 1 0.400000 $19.1800 $47.9400
AACFIT-92609TLGT AAC FITTING, ADJUST, TRAINING VISIT 1 1 0.633333 $30.3600 $47.9400
ASST -ASST ASSISTIVE TECHNOLOGY 27 28 32.538888 $162694.0000 $4999.9900
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.000000 $69.3500 $69.3500
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 3.285714 $227.8600 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 5 5 4.622222 $1070.5900 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 250 312 270.300000 $13515.0000 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 23 25 21.772223 $1088.6200 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 0.250000 $6.2500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 58 68 64.696822 $3234.8400 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 1 1 0.272222 $13.6100 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 112 112 94.202380 $4710.1100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 0.666666 $16.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 81 82 77.335713 $3866.7800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 163 176 153.251583 $7662.5500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 8 8 5.377776 $134.4400 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 8 8 45.485714 $1228.1200 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 389 422 2053.769831 $110903.6500 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 23 26 129.928568 $7016.1700 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 45 47 235.743648 $19170.6800 $81.3200
OCCT -97530GO OT SESSION BY LICENSED OT 5 6 24.142858 $1963.2900 $81.3200
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 2.857143 $232.3400 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 12 13 58.642855 $3818.8300 $65.1200
OCCT -97530TL OT SESSION BY LICENSED OT 25 27 135.344447 $11006.2100 $81.3200
OCCT -97530TLGO OT SESSION BY LICENSED OT 13 14 77.357141 $6290.7100 $81.3200
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 2.133333 $173.4800 $81.3200
OCCT -97530TLHM OT SESSION BY OT ASST 9 10 30.214286 $1967.5600 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 29 29 120.200000 $9774.7000 $81.3200
PHY -97110GPGT PT SESSION BY LICENSED PT 2 2 16.428571 $1335.9700 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 3 3 15.928571 $1295.3100 $81.3200
PHY -97110TL PT SESSION BY LICENSED PT 17 17 72.892063 $5927.5900 $81.3200
PHY -97110TLGT PT SESSION BY LICENSED PT 3 3 14.571428 $1184.9500 $81.3200
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 6 6 8.777778 $4030.9400 $459.2200
SENS -V5264 EARMOLD 5 5 20.185714 $365.9700 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 59 61 304.658728 $24774.8700 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 6 6 35.333334 $2873.3000 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 17 17 34.342065 $2792.7200 $81.3200
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 1.142857 $92.9400 $81.3200
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 681 1554 4173.847587 $416732.0400 $99.8400
-------------------------------------------------------------------------------------------------------------------------------------
Total 1721 4296.473776 $421586.6300 $98.1200
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 690