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 5345 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 85 86 94.088890 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 85 86 94.088890 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 27 29 35.178060 $1706.1400 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $61.7100 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 5 5 14.084921 $213.9500 $15.1900
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.000000 $24.2800 $24.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.000000 $7.9200 $7.9200
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 1.000000 $10.8800 $10.8800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.000000 $15.1900 $15.1900
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.3200 $45.3200
EXIT -EXIT COS Exit 143 148 107.307635 $5365.3700 $50.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 3 6.000000 $359.5200 $59.9200
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 1 1 2.000000 $119.8400 $59.9200
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 7 7 14.000000 $1133.7200 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 6 6 11.000000 $890.7800 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 7 8 16.000000 $1295.6800 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 3 3 6.000000 $485.8800 $80.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 6 6 12.000000 $971.7600 $80.9800
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 3 3 6.000000 $485.8800 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 36 38 75.000000 $4494.0000 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 14 15 29.000000 $1737.6800 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 28 32 63.000000 $5101.7400 $80.9800
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 9 10 20.000000 $1619.6000 $80.9800
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 1.000000 $58.1100 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.000000 $15.1100 $15.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 5 5 5.000000 $290.5500 $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
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 1.142857 $66.4100 $58.1100
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 255 333 434.813473 $26815.2800 $61.6700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 11 12 16.188411 $80942.0000 $5000.0000
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 2 2 11.571429 $2680.1700 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 390 439 475.021151 $23751.0500 $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 11 11 22.500000 $1125.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 6 6 13.166667 $329.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 102 105 172.811105 $8640.5300 $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 -T1027SC EI INDIVIDUAL SESSION BY EI PROF 78 83 549.923810 $29695.8800 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 42 45 284.038093 $15338.0700 $54.0000
INTR -T1013 INTERPRETER 222 289 503.347618 $25167.3900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1174 1528 9430.830492 $113170.0000 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 7 8 30.876191 $2510.8400 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 13 13 78.295238 $6366.9700 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 2 2 18.428571 $1498.6100 $81.3200
PHY -97110TL PT SESSION BY LICENSED PT 1 1 0.571429 $46.4700 $81.3200
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 1.000000 $114.8100 $114.8100
SENS -V5060 BEHIND EAR HEARING AID 1 1 1.000000 $229.6100 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 1.000000 $459.2200 $459.2200
SENS -V5264 EARMOLD 2 2 2.000000 $36.2600 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 22 28 150.299999 $12222.4100 $81.3200
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
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 1447 4926 22557.291400 $391879.3400 $17.3700
-------------------------------------------------------------------------------------------------------------------------------------
Total 5345 23086.193763 $418694.6100 $18.1400
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 1569