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: 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 2864 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 28 28 32.063490 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 28 28 32.063490 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 1.000000 $48.5000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 21 21 18.150000 $1120.0400 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 22 22 16.594443 $252.0700 $15.1900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 19 19 16.740476 $359.2500 $21.4600
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 15 16 7.122223 $172.9300 $24.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 3 1.561111 $12.3600 $7.9200
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 13 13 12.860504 $409.1000 $31.8100
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 33 33 20.672219 $314.0100 $15.1900
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 28 28 22.366667 $517.5700 $23.1400
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.533333 $24.1700 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.088889 $10.3000 $115.8200
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 0.011111 $0.6700 $59.8600
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $119.8400 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $161.9600 $80.9800
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 0.011111 $0.9000 $80.9000
OCTF -97168 OT RE-EVAL EST PLAN CARE 15 17 15.633334 $908.4600 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 40 40 23.766668 $1381.0900 $58.1100
OCTH -97165GT OT EVAL LOW COMPLEXITY 4 4 1.888888 $109.7600 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 3 3 2.222222 $129.1300 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 18 18 13.366667 $776.7400 $58.1100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 14 14 12.594444 $731.8600 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 26 27 14.394448 $836.4800 $58.1100
PSTH -97161TL PT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.400000 $23.2400 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 13 13 7.672222 $445.8300 $58.1100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 2 2 0.705556 $41.0000 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 79 80 48.579367 $2822.9500 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 1.000000 $58.1100 $58.1100
SPCH -92521TL EVAL OF SPEECH FLUENCY 1 1 0.261111 $15.1700 $58.1100
SPCH -92522 EVAL OF SPCH SOUND PROD 8 8 8.300000 $482.3100 $58.1100
SPCH -92522GT EVAL OF SPCH SOUND PROD 1 1 2.000000 $116.2200 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 52 54 37.372223 $2171.7000 $58.1100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.083333 $62.9500 $58.1100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.416667 $82.3200 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 12 13 15.157143 $880.7800 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 18 18 138.714287 $8060.6900 $58.1100
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Subtotal (Total Children Is Unduplicated) 366 483 470.240667 $23776.6700 $50.5600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 7 7 7.661111 $38305.5000 $4999.9900
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 0.133333 $9.2400 $69.3300
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.200000 $13.8700 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 7 7 12.533333 $2902.9600 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 190 254 225.107948 $11255.4600 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 18 24 22.000000 $1100.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 18 19 16.872223 $421.8100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 365 415 930.388089 $46519.3800 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 6 8 18.571428 $928.5700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 2 1.500000 $37.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 165 182 351.058730 $17552.9400 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 4 4 6.900000 $345.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 4 2.866667 $71.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 77 80 94.476190 $4723.8100 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 1 1 2.300000 $115.0000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 194 212 371.906350 $18595.3300 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 5 5 6.566666 $328.3300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 4.999999 $125.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 744 779 5622.058726 $303591.0800 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 39 40 273.552376 $14771.8100 $54.0000
INTR -T1013 INTERPRETER 2 2 20.428571 $1021.4300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 66 71 608.571425 $49489.0300 $81.3200
OCCT -97530GO OT SESSION BY LICENSED OT 3 3 27.714286 $2253.7300 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 9 10 63.361905 $4126.1300 $65.1200
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 8.285714 $539.5600 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 62 64 431.004762 $35049.2700 $81.3200
SENS -V5261 BEHIND EAR DIGITAL BINAURAL HEARING 1 1 0.533333 $523.0300 $980.6800
SENS -V5264 EARMOLD 4 4 3.377778 $61.2400 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 129 132 889.940477 $72369.9100 $81.3200
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 12 13 122.428572 $7972.5500 $65.1200
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 3 3 14.000000 $911.6800 $65.1200
SPL -92507TLGTHM SPL THERAPY SESSION BY SLP ASST 1 1 10.571429 $688.4100 $65.1200
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Subtotal (Total Children Is Unduplicated) 855 2353 10171.871421 $636720.2200 $62.6000
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Total 2864 10674.175578 $660496.8900 $61.8800
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Number of Children (Unduplicated) With at Least One Authorization 896