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: 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 1689 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 24 24 19.924603 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 24 24 19.924603 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 12.746825 $786.6100 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 7 7 6.155556 $93.5000 $15.1900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 6 6 3.422221 $73.4400 $21.4600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.472222 $12.3000 $26.0400
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 3.142857 $50.7600 $16.1500
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 3 3 0.733333 $17.8000 $24.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 4.009524 $31.7600 $7.9200
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 3.731746 $118.7100 $31.8100
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 13 13 8.438887 $128.1800 $15.1900
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 2.000000 $46.2800 $23.1400
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 1 2 2.000000 $116.2200 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 11 12 5.999999 $348.6500 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 5 5 1.716666 $99.7500 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 3 3 3.000000 $174.3300 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 10 10 7.211110 $419.0300 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 2 0.311111 $18.0800 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 26 27 17.933333 $1042.1000 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 1.000000 $58.1100 $58.1100
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 2.000000 $116.2200 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 7 7 7.000000 $406.7700 $58.1100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 2.000000 $116.2200 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $58.1100 $58.1100
SPCH -92610GT EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $58.1100 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 3 3 17.654762 $1025.9100 $58.1100
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 89 117 116.680152 $5536.8000 $47.4500
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 2.000000 $463.2400 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 195 262 219.965885 $10998.3500 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 20 26 22.600000 $1130.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 23 26 24.272223 $606.8100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 340 374 936.288890 $46814.4500 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 10 11 11.300000 $565.0000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 4 4 3.166667 $79.1700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 161 174 347.938097 $17396.9100 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 7 8 11.066667 $553.3400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 3 4.366666 $109.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 88 93 211.799998 $10589.9900 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 3 3 3.400000 $170.0000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 2.433334 $60.8400 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 175 190 370.883332 $18544.1600 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 4 4 3.766667 $188.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 4.766667 $119.1700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 263 278 2135.490497 $115316.4900 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 14 15 61.719049 $3332.8200 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 12 14 88.571430 $7202.6300 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 2 2 6.000000 $390.7200 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 14 14 84.619049 $6881.2200 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 34 36 293.142861 $23838.3700 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 1.000000 $81.3200 $81.3200
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 3 3 32.428572 $2111.7500 $65.1200
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 1 1 2.000000 $130.2400 $65.1200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 1.714286 $139.4100 $81.3200
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 609 1548 4886.700837 $267813.8800 $54.8000
-------------------------------------------------------------------------------------------------------------------------------------
Total 1689 5023.305592 $273350.6800 $54.4200
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 637