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 1792 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
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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 3 3 3.000000 $185.1300 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 6 6 7.388888 $112.2400 $15.1900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 1.000000 $21.4600 $21.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.000000 $16.1500 $16.1500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 3 0.722223 $5.7200 $7.9200
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.000000 $31.8100 $31.8100
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 7 7 1.766667 $26.8400 $15.1900
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 4 4 26.318254 $609.0000 $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
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 1 1 2.000000 $119.8400 $59.9200
OCTF -97168 OT RE-EVAL EST PLAN CARE 4 4 4.000000 $232.4400 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 11 12 9.761111 $567.2200 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 4 4 7.780159 $452.1100 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 6 6 6.000000 $348.6600 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 4 4 2.688889 $156.2500 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 11 12 10.483333 $609.1800 $58.1100
SPCH -92522GT EVAL OF SPCH SOUND PROD 1 1 0.344444 $20.0100 $58.1000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 10 10 9.194445 $534.2900 $58.1100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $58.1100 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $58.1100 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 1.142857 $66.4100 $58.1100
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Subtotal (Total Children Is Unduplicated) 64 86 98.646826 $4295.3400 $43.5400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $231.6200 $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 230 265 510.728571 $25536.4300 $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 276 291 1899.069829 $102549.8400 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 4 4 27.238096 $1470.8600 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 20 21 141.242855 $11485.8800 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 8 8 44.142855 $3589.7100 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 27 29 182.000003 $14800.2400 $81.3200
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 4.857143 $316.2900 $65.1200
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 1 1 22.285714 $1451.2400 $65.1200
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Subtotal (Total Children Is Unduplicated) 670 1687 4729.306352 $260381.8700 $55.0600
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Total 1792 4848.551592 $264677.2100 $54.5900
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Number of Children (Unduplicated) With at Least One Authorization 694