Summary Report for FSPSAs Initiated During the Report Period Center: 53
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: 04-01-24 and 06-30-24 Date of Report: 04-12-25 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 840 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 27 27 32.911110 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 1.033333 $38.4400 $37.2000
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Subtotal (Total Children Is Unduplicated) 28 28 33.944443 $38.4400 $1.1300
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 11 11 8.816667 $427.6100 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 1.288889 $79.5400 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 2 2 0.583333 $8.8600 $15.1900
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 51 52 28.322222 $687.6600 $24.2800
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.988889 $44.8200 $45.3200
EXIT -EXIT COS Exit 1 1 1.000000 $50.0000 $50.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 1 1 1.500000 $121.4700 $80.9800
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 1.500000 $89.8800 $59.9200
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 17.714286 $1029.3800 $58.1100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 1 2.857143 $166.0300 $58.1100
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Subtotal (Total Children Is Unduplicated) 70 73 64.571429 $2705.2400 $41.9000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 13 14 11.050000 $55250.0000 $5000.0000
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 2.000000 $463.2400 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 23 32 20.250000 $1012.5000 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 1 2 1.000000 $50.0000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 5 5 10.361904 $518.1000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 50 51 116.026982 $5801.3400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 6 6 7.883334 $197.0900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 42 43 60.749209 $3037.4700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 56 58 75.184921 $3759.2500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 8 9 7.722223 $193.0600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 257 267 1369.656365 $73961.3600 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 7 7 32.152382 $1736.2200 $54.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 31 35 161.533334 $1938.4000 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 36 37 203.188099 $16523.2400 $81.3200
OCCT -97530TL OT SESSION BY LICENSED OT 35 36 187.392860 $15238.7800 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 30 32 214.685718 $17458.2200 $81.3200
PHY -97110TL PT SESSION BY LICENSED PT 17 17 92.738098 $7541.4500 $81.3200
PHY -97110TLGT PT SESSION BY LICENSED PT 1 1 3.285714 $267.1900 $81.3200
SENS -V5264 EARMOLD 3 3 1.555556 $28.2000 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 36 39 192.090480 $15620.7900 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 4 4 24.276191 $1974.1300 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 37 39 188.823812 $15355.1400 $81.3200
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Subtotal (Total Children Is Unduplicated) 477 739 2983.607182 $237925.1800 $79.7400
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Total 840 3082.123054 $240668.8600 $78.0900
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Number of Children (Unduplicated) With at Least One Authorization 506