Summary Report for FSPSAs Ending During the Report Period Center: 01
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: 07-01-24 and 09-30-24 Date of Report: 04-06-25 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 8146 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 95 96 100.939683 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 95 96 100.939683 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 38 40 46.252033 $2243.2300 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 15 16 23.619048 $1457.5300 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 22 23 44.045499 $669.0500 $15.1900
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 2.000000 $48.5600 $24.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 5 5 4.411111 $34.9400 $7.9200
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 1.000000 $10.8800 $10.8800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.411111 $13.0800 $31.8100
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.000000 $15.1900 $15.1900
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 6 6 10.982540 $254.1400 $23.1400
AUDE -92602 REPROGRAM COCHLEAR IMPLT <7 1 1 7.600000 $461.5500 $60.7300
AUDE -92651 AEP HEARING STATUS DETER I&R 1 1 1.000000 $78.2500 $78.2500
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 2.073973 $93.9900 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.052055 $6.0300 $115.9100
EXIT -EXIT COS Exit 171 179 131.200492 $6560.0200 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 3 6 12.000000 $900.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 6.000000 $485.8800 $80.9800
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 2 2 4.000000 $323.9200 $80.9800
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 3 3 6.000000 $485.8800 $80.9800
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 2.000000 $161.9600 $80.9800
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 1 1 2.000000 $161.9600 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 22 23 46.000000 $2756.3200 $59.9200
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 5 6 12.000000 $719.0400 $59.9200
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 100 101 200.000000 $16196.0000 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 34 34 65.500000 $5304.1900 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 41 42 84.000000 $6802.3200 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 18 18 34.000000 $2753.3200 $80.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 47 47 93.000000 $7531.1400 $80.9800
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 14 14 26.000000 $2105.4800 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 447 462 919.500000 $55096.4400 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 136 140 279.071429 $16721.9600 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 386 442 886.571429 $71794.5500 $80.9800
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 97 117 232.500000 $18827.8500 $80.9800
OCTF -97168 OT RE-EVAL EST PLAN CARE 2 2 2.000000 $116.2200 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 4 4 4.000000 $232.4400 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 1.172603 $68.1400 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 2 3 3.000000 $174.3300 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 0.402740 $23.4000 $58.1000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 2 2 1.073973 $16.2300 $15.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 11 11 11.000000 $639.2100 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 2 2 2.000000 $116.2200 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 5 6 7.000000 $406.7700 $58.1100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $58.1100 $58.1100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.100000 $5.8100 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.202740 $11.7800 $58.1000
SPCH -92610TLGT EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $58.1100 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 10 10 48.714286 $2830.7900 $58.1100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 1 6.142857 $356.9600 $58.1100
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Subtotal (Total Children Is Unduplicated) 1026 1795 3277.599919 $226363.5000 $69.0600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 41 45 50.413981 $252069.5000 $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 2.566667 $178.0000 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 8 8 18.571429 $4301.5100 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 393 442 477.437818 $23871.8900 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 57 63 52.761191 $2638.0400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 39 40 38.837444 $970.9400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 255 272 489.535717 $24476.8000 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 33 34 63.380955 $3169.0600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 2 4.200000 $105.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 104 107 195.095237 $9754.7600 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 12 12 24.766667 $1238.3400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 6 6 13.166667 $329.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 105 108 179.911105 $8995.5300 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 12 12 16.000000 $800.0000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 5 5 11.633333 $290.8300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 176 192 375.371430 $18768.5800 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 16 18 29.199208 $1459.9700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 10 10 17.933332 $448.3300 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 10.571429 $528.5700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 902 953 6498.609506 $350925.0300 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 188 196 1290.314286 $69676.9900 $54.0000
INTR -T1013 INTERPRETER 243 313 545.061904 $27253.1100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1174 1528 9430.830492 $113170.0000 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 35 37 236.766666 $19253.8400 $81.3200
OCCT -97530GO OT SESSION BY LICENSED OT 1 1 -19.857143 $-1614.7800 $81.3200
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 3.571428 $290.4300 $81.3200
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 11.428571 $929.3700 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 83 87 513.061907 $41722.2000 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 7 7 40.590475 $3300.8200 $81.3200
PHY -97110TL PT SESSION BY LICENSED PT 3 3 4.133333 $336.1200 $81.3200
PHY -97110TLGT PT SESSION BY LICENSED PT 1 1 4.466667 $363.2300 $81.3200
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 2 2 1.052055 $120.7900 $114.8100
SENS -V5060 BEHIND EAR HEARING AID 2 2 3.000000 $688.8300 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 3 3 4.000000 $1836.8800 $459.2200
SENS -V5264 EARMOLD 6 6 6.923288 $125.5200 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 118 130 700.242857 $56943.7400 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 7 7 49.504762 $4025.7300 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 3 3 15.571429 $1266.2700 $81.3200
SPL -92508HA GROUP SPL SESSION PER CHILD 2 2 6.428571 $101.3100 $15.7600
TRAN -TRAN *FAMILY TRANSPORTATION 1 1 2.000000 $200.0000 $100.0000
TRAV -TRAVS Travel by mile 1231 1591 9494.906682 $4225.2300 $0.4500
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Subtotal (Total Children Is Unduplicated) 1479 6255 30914.961346 $1049604.8000 $33.9500
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Total 8146 34293.500948 $1275968.3000 $37.2100
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Number of Children (Unduplicated) With at Least One Authorization 2051