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: 01-01-25 and 03-31-25 Date of Report: 04-06-25 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1022 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 63 63 30.699996 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 63 63 30.699996 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 14 14 11.322222 $549.1300 $48.5000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 4 4 3.188889 $101.4400 $31.8100
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 0.544444 $31.6400 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 34 38 23.642855 $1373.8800 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 36 37 16.505557 $959.1500 $58.1100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 0.472222 $27.4400 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 53 60 48.934128 $2843.5700 $58.1100
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Subtotal (Total Children Is Unduplicated) 123 156 104.610317 $5886.2300 $56.2700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 14 14 13.777778 $68889.0000 $5000.0100
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.189041 $43.7800 $231.5700
CONIF -CONIF CONSULT, ITDS FACE TO FACE 7 7 20.038096 $1001.9100 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 69 77 86.200004 $4310.0200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 25 29 26.222223 $1311.1200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 51 57 70.741271 $3537.0700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 328 437 1756.685742 $94861.0500 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 2 2 2.285714 $123.4300 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 37 49 186.319050 $15151.4500 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 40 52 223.450003 $18170.9400 $81.3200
SENS -V5261 BEHIND EAR DIGITAL BINAURAL HEARING 1 1 0.189041 $185.3600 $980.5300
SENS -V5264 EARMOLD 1 1 0.567123 $10.2800 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 56 76 328.352383 $26701.6000 $81.3200
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Subtotal (Total Children Is Unduplicated) 464 803 2715.017469 $234297.0000 $86.3000
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Total 1022 2850.327782 $240183.2300 $84.2700
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Number of Children (Unduplicated) With at Least One Authorization 521