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 1798 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
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 4 4 2.066666 $31.3900 $15.1900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 2 2 1.588889 $34.1000 $21.4600
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 0.411111 $9.9800 $24.2800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.344444 $10.9600 $31.8100
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 7 7 4.400000 $66.8400 $15.1900
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 1.533333 $35.4800 $23.1400
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 5 5 4.066667 $236.3200 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 8 9 6.066666 $352.5300 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 4 4 4.255556 $247.2900 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 7 7 5.655555 $328.6400 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 1.400000 $81.3500 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.116667 $6.7800 $58.1300
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 0.111111 $6.4600 $58.1000
SPCH -92521 EVAL OF SPEECH FLUENCY 21 23 17.255556 $1002.7200 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 10 10 8.050000 $467.7900 $58.1100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.077778 $4.5200 $58.1300
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $58.1100 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 6.142857 $356.9600 $58.1100
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Subtotal (Total Children Is Unduplicated) 69 85 67.542856 $3517.9800 $52.0900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 2.300000 $11500.0000 $5000.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 2.933333 $203.4200 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 6.000000 $1389.7200 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 221 284 231.586527 $11579.4100 $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 196 211 388.642854 $19432.1300 $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 288 303 2147.033354 $115939.8300 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 2 3 13.666667 $738.0000 $54.0000
INTR -T1013 INTERPRETER 2 2 11.857143 $592.8600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 14 15 92.090475 $7488.8200 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 10 10 84.428571 $6865.7400 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 1 1 8.857143 $720.2600 $81.3200
SENS -V5264 EARMOLD 1 1 3.000000 $54.3900 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 34 36 215.285720 $17507.0100 $81.3200
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 3 3 24.000000 $1562.8800 $65.1200
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Subtotal (Total Children Is Unduplicated) 665 1681 4884.254802 $278027.6900 $56.9200
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Total 1798 4992.420675 $281545.6700 $56.3900
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Number of Children (Unduplicated) With at Least One Authorization 695