Summary Report for FSPSAs Initiated During the Report Period Center: 01
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: 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 8028 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 114 116 151.241280 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 114 116 151.241280 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 41 42 45.380344 $2200.9500 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 7 8 8.633334 $532.7700 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 18 19 37.260318 $565.9800 $15.1900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 1.666667 $35.7700 $21.4600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 3 3 4.238096 $110.3600 $26.0400
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 2.666667 $43.0700 $16.1500
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 3 3 3.666667 $89.0300 $24.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 3 3.666667 $29.0400 $7.9200
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 3 3 3.666667 $116.6400 $31.8100
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 2 2.666667 $132.2400 $49.5900
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 2.666667 $40.5100 $15.1900
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 9 9 30.952381 $716.2400 $23.1400
AUDE -92651 AEP HEARING STATUS DETER I&R 1 1 1.000000 $78.2500 $78.2500
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.000000 $90.6400 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.8100 $115.8100
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 42 43 86.000000 $6964.2800 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 17 17 32.000000 $2591.3600 $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 448 463 921.500000 $55216.2800 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 135 139 277.071429 $16602.1200 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 386 442 886.714286 $71806.1200 $80.9800
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 96 116 230.500000 $18665.8900 $80.9800
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 1.172603 $68.1400 $58.1100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 3 4 5.000000 $290.5500 $58.1100
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.249315 $18.8800 $15.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 10 10 10.000000 $581.1000 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 3 3 3.000000 $174.3300 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 2.189041 $127.2100 $58.1100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 2.000000 $116.2200 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 5 5 33.666667 $1956.3800 $58.1100
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Subtotal (Total Children Is Unduplicated) 983 1779 3255.894975 $224174.7000 $68.8500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 38 43 35.352033 $176761.0000 $5000.0200
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 2.000000 $138.7000 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 4 5 6.000000 $1389.7200 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 391 437 469.537819 $23476.8900 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 55 60 47.294524 $2364.7100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 39 40 40.037444 $1000.9400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 274 289 515.233327 $25761.6300 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 18 20 16.048412 $802.4200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 0.350000 $8.7500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 105 109 201.242057 $10062.0700 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 5 5 17.047620 $852.3900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 5 6 9.600000 $240.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 107 108 161.333330 $8066.6500 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 7 7 8.666667 $433.3400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 1.966667 $49.1700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 182 188 306.088088 $15304.3700 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 11 13 5.172222 $258.6100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 5.483333 $137.0800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 929 987 6245.619118 $337263.4700 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 142 147 916.714293 $49502.5800 $54.0000
INTR -T1013 INTERPRETER 237 316 553.861906 $27693.1000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1154 1495 8567.322667 $102807.8800 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 40 43 295.109527 $23998.3000 $81.3200
OCCT -97530GO OT SESSION BY LICENSED OT 2 2 4.533333 $368.6500 $81.3200
OCCT -97530GOGT OT SESSION BY LICENSED OT 1 1 1.733333 $140.9500 $81.3200
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 9.857143 $801.5800 $81.3200
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 1.714286 $139.4100 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 76 78 460.023817 $37409.1400 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 15 16 128.419049 $10443.0300 $81.3200
PHY -97110TL PT SESSION BY LICENSED PT 1 1 5.533333 $449.9700 $81.3200
PHY -97110TLGT PT SESSION BY LICENSED PT 1 1 5.142857 $418.2200 $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 2.000000 $459.2200 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 3 5.000000 $2296.1000 $459.2200
SENS -V5264 EARMOLD 6 7 5.177169 $93.8600 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 100 108 617.166675 $50188.0000 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 13 14 89.666667 $7291.6900 $81.3200
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 4 4 15.000001 $976.7900 $65.1200
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 2 2 10.714286 $697.7100 $65.1200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 2 2 24.428571 $1986.5300 $81.3200
SPL -92508HA GROUP SPL SESSION PER CHILD 3 3 23.000000 $362.4800 $15.7600
TRAN -TRAN *FAMILY TRANSPORTATION 1 1 2.000000 $200.0000 $100.0000
TRAV -TRAVS Travel by mile 1179 1560 8599.408381 $3826.7500 $0.4500
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Subtotal (Total Children Is Unduplicated) 1365 6133 28438.599955 $927038.6400 $32.6000
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Total 8028 31845.736210 $1151213.3400 $36.1500
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Number of Children (Unduplicated) With at Least One Authorization 1731