Summary Report for FSPSAs Ending During the Report Period Center: 02
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: 01-01-24 and 03-31-24 Date of Report: 04-04-25 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2560 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 2 2 0.544445 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 0.544445 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 28 28 17.525266 $849.9700 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 3 3 1.924201 $118.7500 $61.7100
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.238356 $3.8500 $16.1500
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.000000 $24.2800 $24.2800
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 1 1 0.244444 $19.8600 $81.2300
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.433333 $19.6400 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 1.433333 $165.9900 $115.8100
EXIT -EXIT COS Exit 2 2 1.066667 $53.3400 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 3 5 9.000000 $675.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 6.000000 $485.8800 $80.9800
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 4.000000 $323.9200 $80.9800
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 66 69 111.965748 $9067.0100 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 16 17 33.500000 $2712.8300 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 42 42 84.000000 $6802.3200 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 11 11 21.000000 $1700.5800 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 84 89 152.565748 $9141.7600 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 23 24 47.500000 $2846.2000 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 55 76 145.000000 $11742.1000 $80.9800
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 11 17 34.000000 $2753.3200 $80.9800
OCTF -97168 OT RE-EVAL EST PLAN CARE 2 2 0.528615 $30.7200 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 27 27 9.089572 $528.1900 $58.1100
OCTH -97165GT OT EVAL LOW COMPLEXITY 5 5 5.183333 $301.2000 $58.1100
OCTH -97165TL OT EVAL LOW COMPLEXITY 1 1 0.366667 $21.3100 $58.1200
OCTH -97166 OT EVAL MODERATE COMPLEXITY 13 13 11.713275 $680.6700 $58.1100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 0.057534 $3.3400 $58.0800
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 1 1 0.057534 $3.3400 $58.0800
OCTH -97167 OT EVAL HIGH COMPLEXITY 6 6 2.750533 $159.8300 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 2 0.223973 $13.0200 $58.1200
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 0.084932 $4.9300 $58.0900
PSTH -97161 PT EVAL LOW COMPLEXITY 26 26 15.734909 $914.3600 $58.1100
PSTH -97161GT PT EVAL LOW COMPLEXITY 2 2 0.505555 $29.3700 $58.1000
PSTH -97162 PT EVAL MODERATE COMPLEXITY 5 5 3.194445 $185.6300 $58.1100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 0.134247 $7.8000 $58.0900
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 1 1 1.733333 $100.7200 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 39 39 15.080898 $876.3500 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 4 4 2.538889 $147.5400 $58.1100
SPCH -92521TL EVAL OF SPEECH FLUENCY 1 1 1.000000 $58.1100 $58.1100
SPCH -92522 EVAL OF SPCH SOUND PROD 5 5 0.866895 $50.3800 $58.1100
SPCH -92522TL EVAL OF SPCH SOUND PROD 1 1 0.104110 $6.0500 $58.1000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 15 16 10.387671 $603.6300 $58.1100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.083333 $4.8400 $58.0900
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 0.811111 $47.1300 $58.1100
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Subtotal (Total Children Is Unduplicated) 288 558 755.628460 $54343.1300 $71.9200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 28 28 45.813460 $229068.5000 $5000.0300
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 61 62 59.791250 $2989.5400 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 9 10 9.604166 $480.2100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.233333 $30.8300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 200 229 355.280962 $17764.1000 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 2 2 1.966667 $98.3400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 2 2.000000 $50.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 115 122 158.433336 $7921.6800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.500000 $37.5000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 7 7 7.833334 $391.6700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.133333 $3.3300 $24.9900
CONSF -CONSF CONSULT, SLP, FACE TO FACE 184 192 286.633341 $14331.7000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 5 8.166667 $204.1700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 4 32.571428 $1628.5700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 183 191 1243.152370 $67130.2400 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 31 31 189.152382 $10214.2200 $54.0000
INTR -T1013 INTERPRETER 14 22 42.865362 $2143.2700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 210 418 1585.409522 $19024.9200 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 69 69 447.022225 $36351.8400 $81.3200
OCCT -97530GT OT SESSION BY LICENSED OT 5 5 45.857143 $3729.1000 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 40 41 316.161114 $25710.2100 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 1 1 7.000000 $569.2400 $81.3200
PHY -97110HM PT SESSION BY PT ASST 4 4 29.857143 $1944.2900 $65.1200
SENS -V5060 BEHIND EAR HEARING AID 2 2 2.433333 $558.7100 $229.6100
SENS -V5264 EARMOLD 2 2 1.433790 $25.9900 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 79 81 482.895237 $39269.0500 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 7 7 52.285715 $4251.8700 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 5.142857 $418.2200 $81.3200
TRAV -TRAVS Travel by mile 217 459 92065.690472 $40969.2300 $0.4500
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Subtotal (Total Children Is Unduplicated) 305 2000 97487.319942 $527310.5300 $5.4100
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Total 2560 98243.492847 $581653.6600 $5.9200
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Number of Children (Unduplicated) With at Least One Authorization 438