Summary Report for FSPSAs Ending During the Report Period Center: 03
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 1236 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 72 74 50.384124 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 72 74 50.384124 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 14 15 13.450000 $652.3300 $48.5000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 2.000000 $63.6200 $31.8100
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 0.528767 $61.2400 $115.8200
OCTH -97165 OT EVAL LOW COMPLEXITY 8 8 4.672223 $271.5100 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 27 27 13.016667 $756.4000 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 56 65 35.052383 $2036.9100 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 84 87 58.865873 $3420.6900 $58.1100
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Subtotal (Total Children Is Unduplicated) 162 208 128.585913 $7320.8000 $56.9300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 10 10 10.000000 $50000.0000 $5000.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 13 13 13.344446 $667.2300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 51 54 65.726989 $3286.3800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 50 52 52.061112 $2603.0600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 75 85 95.138895 $4756.9800 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 3.266667 $163.3400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 400 478 1841.138086 $99421.4800 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 9.142857 $493.7200 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 46 48 195.309522 $15882.5800 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 71 84 326.214284 $26527.7700 $81.3200
SENS -V5050 IN EAR MONAURAL HEARING AID 3 3 0.528767 $121.4200 $229.6200
SENS -V5264 EARMOLD 3 3 0.528767 $9.5900 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 111 122 513.052376 $41721.4100 $81.3200
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Subtotal (Total Children Is Unduplicated) 618 954 3125.452768 $245654.9400 $78.6000
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Total 1236 3304.422805 $252975.7400 $76.5600
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Number of Children (Unduplicated) With at Least One Authorization 693