Summary Report for FSPSAs Ending During the Report Period Center: 07
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 3177 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 19 19 20.598414 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 19 19 20.598414 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 23 23 22.299999 $1376.1300 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 18 18 14.805556 $224.9000 $15.1900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 25 26 16.850001 $361.6000 $21.4600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.000000 $26.0400 $26.0400
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.000000 $16.1500 $16.1500
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 10 10 27.334922 $663.6900 $24.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 5 5 1.772223 $14.0400 $7.9200
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 15 15 17.738096 $564.2500 $31.8100
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 51 51 25.494446 $387.2600 $15.1900
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 19 19 40.584920 $939.1300 $23.1400
AUDE -92651 AEP HEARING STATUS DETER I&R 1 1 0.027778 $2.1800 $78.3100
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 1 1 0.027778 $2.2600 $81.3100
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.666667 $30.2100 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 1.633333 $189.1500 $115.8100
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 1.000000 $59.9200 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 6 6 11.142857 $667.6800 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 5 5 8.142857 $659.4100 $80.9800
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 4.000000 $323.9200 $80.9800
OCTF -97168 OT RE-EVAL EST PLAN CARE 23 26 24.305555 $1412.3900 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 32 34 21.833335 $1268.7400 $58.1100
OCTH -97165TL OT EVAL LOW COMPLEXITY 1 1 0.011111 $0.6500 $58.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 7 7 7.088889 $411.9400 $58.1100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 2.000000 $116.2200 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 34 35 32.869048 $1910.0200 $58.1100
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 3 3 2.322222 $134.9400 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 16 16 14.477778 $841.3000 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 25 26 13.594443 $789.9600 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 3 2.011111 $116.8700 $58.1100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 12 13 8.677778 $504.2700 $58.1100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 0.250000 $14.5300 $58.1100
PSTH -97163TLGT PT EVAL HIGH COMPLEXITY 2 2 1.322222 $76.8300 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 74 77 58.405555 $3393.9400 $58.1100
SPCH -92521TL EVAL OF SPEECH FLUENCY 2 2 0.694445 $40.3600 $58.1100
SPCH -92522 EVAL OF SPCH SOUND PROD 4 4 6.355556 $369.3200 $58.1100
SPCH -92522GT EVAL OF SPCH SOUND PROD 1 1 0.344444 $20.0100 $58.1000
SPCH -92522TL EVAL OF SPCH SOUND PROD 1 1 2.000000 $116.2200 $58.1100
SPCH -92522TLGT EVAL OF SPCH SOUND PROD 1 1 2.000000 $116.2200 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 80 84 57.050000 $3315.1800 $58.1100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 3 4 1.633333 $94.9100 $58.1100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.477778 $27.7700 $58.1100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.311111 $76.1900 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 10 10 9.861111 $573.0300 $58.1100
SPCH -92610TLGT EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $58.1100 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 11 11 89.428573 $5196.7000 $58.1100
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 412 556 557.846831 $27562.6600 $49.4100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.000000 $15000.0000 $5000.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.000000 $69.3500 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 8 8 12.555556 $2908.1300 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 218 280 241.265098 $12063.3400 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 11 11 9.250000 $462.5000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 5 5 30.295237 $757.3800 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 391 438 964.630953 $48231.5400 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 3 4 15.533334 $776.6700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 210 225 446.299999 $22315.0000 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 7 7 8.066667 $403.3400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 1.833333 $45.8300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 80 85 166.199998 $8309.9900 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 1 1 1.866667 $93.3400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 231 266 512.528571 $25626.4300 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 5 5 9.133333 $456.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 1.366667 $34.1700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 806 857 6273.145998 $338750.0800 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 29 30 219.992062 $11879.5800 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 96 104 765.499998 $62250.4400 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 60 66 427.714288 $34781.7500 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 1 1 4.285714 $348.5100 $81.3200
SENS -V5060 BEHIND EAR HEARING AID 1 1 2.000000 $459.2200 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 2.000000 $918.4400 $459.2200
SENS -V5264 EARMOLD 5 5 16.682540 $302.4500 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 166 182 1188.761908 $96670.1600 $81.3200
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 10 10 104.838095 $6827.0500 $65.1200
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 2 2 37.142857 $2418.7400 $65.1200
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 960 2602 11466.888873 $693160.0800 $60.4500
-------------------------------------------------------------------------------------------------------------------------------------
Total 3177 12045.334118 $720722.7400 $59.8300
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 1004