Summary Report for FSPSAs Initiated During the Report Period Center: 02
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: 07-01-24 and 09-30-24 Date of Report: 04-06-25 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2074 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 3 3 6.814286 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 6.814286 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 35 35 30.501304 $1479.3100 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 4 4 3.076712 $189.8600 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 2 2 1.061111 $16.1200 $15.1900
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.000000 $24.2800 $24.2800
EXIT -EXIT COS Exit 9 9 8.002740 $400.1400 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 5 7 14.000000 $1050.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 3 4.005479 $324.3700 $80.9800
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.000000 $161.9600 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 0.005479 $0.3300 $60.1600
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 1 1 2.000000 $119.8400 $59.9200
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 81 81 140.054790 $11341.6500 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 19 19 36.005556 $2915.7300 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 46 47 88.500000 $7166.7300 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 20 21 42.000000 $3401.1600 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 92 93 161.054790 $9650.4200 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 27 27 54.000000 $3235.6800 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 62 85 165.500000 $13402.1900 $80.9800
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 12 21 42.000000 $3401.1600 $80.9800
OCTF -97168 OT RE-EVAL EST PLAN CARE 2 2 0.268493 $15.6000 $58.1100
OCTF -97168GT OT RE-EVAL EST PLAN CARE 2 2 0.219179 $12.7400 $58.1200
OCTH -97165 OT EVAL LOW COMPLEXITY 37 40 25.239878 $1466.7000 $58.1100
OCTH -97165GT OT EVAL LOW COMPLEXITY 2 2 0.933334 $54.2400 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 18 18 9.540563 $554.4000 $58.1100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 2 2 1.167123 $67.8200 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 0.255556 $14.8500 $58.1200
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 2 0.205479 $11.9400 $58.0900
PSTH -97161 PT EVAL LOW COMPLEXITY 19 20 10.067350 $585.0100 $58.1100
PSTH -97161GT PT EVAL LOW COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 6 7 3.635618 $211.2700 $58.1100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 45 46 27.444292 $1594.7900 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 1.000000 $58.1100 $58.1100
SPCH -92522 EVAL OF SPCH SOUND PROD 11 13 8.788704 $510.7100 $58.1100
SPCH -92522GT EVAL OF SPCH SOUND PROD 5 5 0.720396 $41.8600 $58.1100
SPCH -92522TLGT EVAL OF SPCH SOUND PROD 1 1 0.093151 $5.4200 $58.1400
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 15 15 22.015656 $1279.3300 $58.1100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $58.1100 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 0.300000 $17.4300 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 4.000000 $232.4400 $58.1100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 1 11.142857 $647.5100 $58.1100
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Subtotal (Total Children Is Unduplicated) 285 643 925.805590 $65895.5500 $71.1800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 36 36 69.082062 $345410.5000 $5000.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.533333 $355.1400 $231.6100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 72 74 78.227277 $3911.3500 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 15 15 17.250000 $862.5000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 212 230 395.871415 $19793.5100 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 5 5 6.200001 $310.0100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.100000 $27.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 125 131 201.909521 $10095.4600 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 1 1 1.333333 $66.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.933333 $23.3300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 3 3 1.933333 $96.6700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 3.000000 $75.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 193 196 309.390466 $15469.4700 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 1 1 0.666667 $33.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 2.933333 $73.3300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 209 215 1436.328594 $77561.7100 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 19 19 161.571431 $8724.8500 $54.0000
INTR -T1013 INTERPRETER 23 34 65.700487 $3285.0300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 47 101 397.576191 $4770.9100 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 77 83 478.833347 $38938.6800 $81.3200
OCCT -97530GOGT OT SESSION BY LICENSED OT 1 1 0.266667 $21.6900 $81.3300
PHY -97110 PT SESSION BY LICENSED PT 29 31 231.187303 $18800.1600 $81.3200
PHY -97110HM PT SESSION BY PT ASST 3 3 24.285715 $1581.4800 $65.1200
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 1.533333 $704.1200 $459.2100
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 95 98 631.008447 $51313.6000 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 13.000000 $1057.1600 $81.3200
TRAV -TRAVS Travel by mile 61 139 22560.240575 $10039.3100 $0.4500
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Subtotal (Total Children Is Unduplicated) 331 1428 27092.896164 $613402.4500 $22.6400
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Total 2074 28025.516040 $679298.0100 $24.2400
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Number of Children (Unduplicated) With at Least One Authorization 389