Summary Report for FSPSAs Initiated During the Report Period Center: 54
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 1575 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 13 13 13.588890 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 13 13 13.588890 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AACIS -92597 AAC INTIAL EVAL BY LICENSED SLP 5 5 4.316667 $504.3200 $116.8300
AACIS -92597TL AAC INTIAL EVAL BY LICENSED SLP 1 1 1.000000 $116.8300 $116.8300
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 49 56 48.107143 $2333.1900 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 7 7 5.327778 $328.7800 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 3 3 1.100000 $16.7100 $15.1900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 1.000000 $21.4600 $21.4600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.000000 $26.0400 $26.0400
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 2.000000 $32.3000 $16.1500
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 25 25 25.372221 $616.0300 $24.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 2.000000 $15.8400 $7.9200
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 2.000000 $63.6200 $31.8100
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 3 3 2.455556 $121.7700 $49.5900
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 2.000000 $30.3800 $15.1900
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 3 3 2.122222 $49.1100 $23.1400
AUDE -V5010 ASSESSMENT FOR HEARING AID 20 20 9.016667 $408.6400 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.338889 $39.2500 $115.8100
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 103 134 109.157143 $4724.2700 $43.2800
EI Services, Class # 03
AACFIT-92609 AAC FITTING, ADJUST, TRAINING VISIT 9 9 5.455555 $261.5400 $47.9400
ASST -ASST ASSISTIVE TECHNOLOGY 24 25 30.094443 $150471.5000 $4999.9800
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 3.000000 $694.8600 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 226 267 240.065475 $12003.2700 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 10 12 11.850000 $592.5000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 0.272222 $6.8100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 69 86 93.669840 $4683.4900 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 1 1 1.000000 $50.0000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 109 113 109.612697 $5480.6300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.277778 $6.9500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 78 82 80.302382 $4015.1100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 155 163 141.594440 $7079.7000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 6 8 4.172221 $104.3000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 10.857143 $293.1400 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 387 406 1972.458752 $106512.6900 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 27 28 125.928573 $6800.1400 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 41 41 187.566672 $15252.9200 $81.3200
OCCT -97530GO OT SESSION BY LICENSED OT 2 2 10.285714 $836.4300 $81.3200
OCCT -97530GOGT OT SESSION BY LICENSED OT 1 1 0.785714 $63.8900 $81.3200
OCCT -97530GT OT SESSION BY LICENSED OT 3 3 17.214286 $1399.8700 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 14 14 51.247619 $3337.2300 $65.1200
OCCT -97530TL OT SESSION BY LICENSED OT 20 20 101.566668 $8259.4000 $81.3200
OCCT -97530TLGO OT SESSION BY LICENSED OT 11 11 63.119048 $5132.8400 $81.3200
OCCT -97530TLHM OT SESSION BY OT ASST 7 7 38.142858 $2483.8500 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 26 27 73.157143 $5949.1400 $81.3200
PHY -97110GPGT PT SESSION BY LICENSED PT 1 1 1.142857 $92.9400 $81.3200
PHY -97110TL PT SESSION BY LICENSED PT 18 19 66.749208 $5428.0300 $81.3200
PHY -97110TLGT PT SESSION BY LICENSED PT 1 1 3.000000 $243.9600 $81.3200
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 3 3 4.338889 $1992.5100 $459.2200
SENS -V5261 BEHIND EAR DIGITAL BINAURAL HEARING 1 1 1.000000 $980.7400 $980.7400
SENS -V5264 EARMOLD 3 3 11.168254 $202.4800 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 42 43 213.846036 $17389.9500 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 14.785715 $1202.3700 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 20 20 64.996827 $5285.5200 $81.3200
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 2 2 13.000000 $1057.1600 $81.3200
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 639 1428 3767.725029 $375647.8200 $99.7000
-------------------------------------------------------------------------------------------------------------------------------------
Total 1575 3890.471062 $380372.1000 $97.7700
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 653