Summary Report for FSPSAs Initiated During the Report Period Center: 07
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 3090 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 32 32 40.623017 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 32 32 40.623017 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 13 13 8.022222 $495.0500 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 25 25 19.066665 $289.6200 $15.1900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 23 23 18.538888 $397.8400 $21.4600
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 16 16 8.433333 $204.7600 $24.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.000000 $7.9200 $7.9200
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 13 14 9.926406 $315.7500 $31.8100
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 36 36 18.888888 $286.9200 $15.1900
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 29 29 23.355555 $540.4500 $23.1400
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 2.566667 $116.3200 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.372222 $43.1000 $115.8000
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 4 4 7.142857 $428.0000 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 3 3 4.142857 $335.4900 $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 17 19 17.283334 $1004.3400 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 42 45 31.327775 $1820.4400 $58.1100
OCTH -97165GT OT EVAL LOW COMPLEXITY 2 2 0.472222 $27.4400 $58.1100
OCTH -97165TL OT EVAL LOW COMPLEXITY 1 1 1.011111 $58.7600 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 3 3 1.200000 $69.7300 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 26 27 21.383333 $1242.5800 $58.1100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 0.433333 $25.1800 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 16 16 11.833333 $687.6300 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 20 22 11.055555 $642.4400 $58.1100
PSTH -97161TL PT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 2.127778 $123.6500 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 13 13 8.716665 $506.5200 $58.1100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 0.300000 $17.4300 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 80 85 63.688889 $3700.9600 $58.1100
SPCH -92521TL EVAL OF SPEECH FLUENCY 1 1 0.455556 $26.4700 $58.1200
SPCH -92522 EVAL OF SPCH SOUND PROD 9 10 13.622223 $791.5900 $58.1100
SPCH -92522GT 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 67 67 42.361108 $2461.5900 $58.1100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.411111 $23.8900 $58.1100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $58.1100 $58.1100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 1.277778 $74.2500 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 10 10 31.753175 $1845.1800 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 10 11 119.285714 $6931.7000 $58.1100
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Subtotal (Total Children Is Unduplicated) 399 514 512.456553 $26275.5100 $51.2700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 6 7.300000 $36500.0000 $5000.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 2.933333 $203.4200 $69.3500
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.822222 $126.3700 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 8 8 16.566667 $3837.1800 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 222 285 231.786527 $11589.4100 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 12 12 10.250000 $512.5000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 3 3 2.116667 $52.9200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 388 448 1024.622227 $51231.1300 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 3 4 6.838095 $341.9100 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 197 212 388.842854 $19442.1300 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 2 2 3.500000 $175.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.000000 $25.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 78 81 154.161903 $7708.0900 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 1 1 0.500000 $25.0000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 220 248 441.950789 $22097.5200 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 3 3 3.733334 $186.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 3.900000 $97.5000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 806 855 6106.490529 $329750.5900 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 25 27 192.800002 $10411.2000 $54.0000
INTR -T1013 INTERPRETER 2 2 11.857143 $592.8600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 80 90 646.014286 $52533.9300 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 2 2 8.285714 $539.5700 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 61 67 539.109528 $43840.4200 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 1 1 8.857143 $720.2600 $81.3200
SENS -V5261 BEHIND EAR DIGITAL BINAURAL HEARING 1 1 2.566667 $2517.2700 $980.7500
SENS -V5264 EARMOLD 4 4 5.883333 $106.6600 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 150 165 1170.285724 $95167.6100 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 9.714286 $789.9700 $81.3200
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 10 10 66.000000 $4297.9300 $65.1200
SPL -92507TLGTHM SPL THERAPY SESSION BY SLP ASST 1 1 3.000000 $195.3600 $65.1200
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Subtotal (Total Children Is Unduplicated) 989 2544 11072.688973 $695615.3500 $62.8200
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Total 3090 11625.768543 $721890.8600 $62.0900
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Number of Children (Unduplicated) With at Least One Authorization 1028