Summary Report for FSPSAs Initiated During the Report Period Center: 03
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 1273 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 64 65 33.492062 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 64 65 33.492062 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 15 15 12.683334 $615.1500 $48.5000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.000000 $31.8100 $31.8100
OCTH -97165 OT EVAL LOW COMPLEXITY 4 4 2.077777 $120.7400 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 39 43 30.624602 $1779.5900 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 3 3 3.000000 $174.3300 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 53 60 27.577781 $1602.5600 $58.1100
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 1.000000 $58.1100 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 81 87 43.576193 $2532.2300 $58.1100
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 178 214 121.539687 $6914.5100 $56.8900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 13 14 11.802436 $59012.5000 $5000.0300
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.167123 $38.7000 $231.5900
CONIF -CONIF CONSULT, ITDS FACE TO FACE 11 11 14.066667 $703.3400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 54 61 76.444445 $3822.2300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 51 56 59.505553 $2975.2700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 85 96 86.472226 $4323.6300 $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 354 496 1884.704777 $101774.0400 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 4.000000 $216.0000 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 46 61 216.404759 $17598.0100 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 67 87 397.114289 $32293.3100 $81.3200
SENS -V5261 BEHIND EAR DIGITAL BINAURAL HEARING 1 1 0.167123 $163.8800 $980.6100
SENS -V5264 EARMOLD 1 1 0.501370 $9.0900 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 83 107 421.257148 $34256.6200 $81.3200
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 551 994 3175.874583 $257349.9500 $81.0300
-------------------------------------------------------------------------------------------------------------------------------------
Total 1273 3330.906332 $264264.4600 $79.3400
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 618