Summary Report for FSPSAs Initiated During the Report Period Center: 01
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 8132 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 86 88 46.533334 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 86 88 46.533334 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 45 46 48.044598 $2330.1700 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 12 12 20.804763 $1283.8600 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 20 21 33.792857 $513.3100 $15.1900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 2.033333 $43.6300 $21.4600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 2.033333 $52.9500 $26.0400
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 2.033333 $32.8400 $16.1500
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 3.033333 $73.6500 $24.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 6 6 7.033333 $55.7000 $7.9200
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 14.033333 $446.4000 $31.8100
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 2.033333 $100.8300 $49.5900
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 2.033333 $30.8900 $15.1900
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 3 3 4.033333 $93.3300 $23.1400
AUDE -92650 AEP SCR AUDITORY POTENTIAL 1 1 1.000000 $54.9000 $54.9000
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 1 1 0.444444 $36.1000 $81.2300
AUDE -V5010 ASSESSMENT FOR HEARING AID 6 6 5.191781 $235.2900 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.000000 $231.6200 $115.8100
EXIT -EXIT COS Exit 126 140 121.723549 $6086.1800 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 16 27 54.000000 $4050.0000 $75.0000
IPDEF -IPDEF_NM F/U PSYCH & DEV EVAL BY NON-MED PRO 1 1 2.000000 $111.0000 $55.5000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 4 4 8.000000 $647.8400 $80.9800
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 1 1 2.000000 $161.9600 $80.9800
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 2 2 4.000000 $323.9200 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 18 20 39.500000 $2366.8400 $59.9200
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 1 1 2.000000 $119.8400 $59.9200
IPDEF -T1024TSTL F/U PSYCH AND DEV EVAL BY EI PROF 5 6 11.500000 $931.2700 $80.9800
IPDEF -T1024TSTLGT F/U PHYC AND DEV EVAL BY EI PROF 1 2 4.000000 $323.9200 $80.9800
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 90 101 198.500000 $16074.5300 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 31 31 50.000000 $4049.0000 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 30 31 61.000000 $4939.7800 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 17 17 31.000000 $2510.3800 $80.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 43 43 86.000000 $6964.2800 $80.9800
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 19 19 34.000000 $2753.3200 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 418 460 928.000000 $55605.7600 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 133 137 259.500000 $15549.2400 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 351 398 791.285714 $64078.3200 $80.9800
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 102 125 244.000000 $19759.1200 $80.9800
OCTH -97165 OT EVAL LOW COMPLEXITY 8 8 8.000000 $464.8800 $58.1100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 3.571429 $207.5300 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 1.000000 $58.1100 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 5 5 4.032877 $234.3500 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 2 2 1.114003 $16.8300 $15.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 10 10 10.000000 $581.1000 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 3 3 3.000000 $174.3300 $58.1100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $58.1100 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 3 3 32.580953 $1893.2800 $58.1100
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Subtotal (Total Children Is Unduplicated) 920 1711 3148.886965 $216884.8300 $68.8800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 36 36 38.854185 $194271.5000 $5000.0100
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.000000 $69.3500 $69.3500
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 1.727777 $119.8200 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 5 5 6.000000 $1389.7200 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 412 456 504.174041 $25208.6900 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 81 92 78.297949 $3914.8900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 57 58 55.557861 $1388.9500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 246 276 526.075391 $26303.7400 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 40 46 69.866666 $3493.3300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 6 6 8.233334 $205.8400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 93 102 160.022214 $8001.0700 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 17 17 34.604761 $1730.2300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 8 9 10.216668 $255.4200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 103 105 196.437300 $9821.8500 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 13 13 16.312700 $815.6400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 3 3 3.500001 $87.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 138 144 271.337300 $13566.8500 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 22 23 42.085713 $2104.2800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 8 8 14.666667 $366.6700 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 2 2 14.285714 $714.2900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 959 1050 6413.279455 $346316.9900 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 116 133 711.457150 $38418.6800 $54.0000
INTR -T1013 INTERPRETER 215 273 466.214286 $23310.7200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1149 1540 8543.124709 $102517.4600 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 39 41 234.133338 $19039.7000 $81.3200
OCCT -97530GO OT SESSION BY LICENSED OT 3 3 4.390476 $357.0300 $81.3200
OCCT -97530GOGT OT SESSION BY LICENSED OT 2 2 7.971429 $648.2300 $81.3200
OCCT -97530TL OT SESSION BY LICENSED OT 4 4 11.571428 $940.9900 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 85 92 559.271436 $45479.9300 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 11 11 86.600001 $7042.3000 $81.3200
PHY -97110TL PT SESSION BY LICENSED PT 2 2 13.285715 $1080.3900 $81.3200
PHY -97110TLGT PT SESSION BY LICENSED PT 2 2 3.866667 $314.4400 $81.3200
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 1.000000 $114.8100 $114.8100
SENS -V5060 BEHIND EAR HEARING AID 2 2 3.000000 $688.8300 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 3.000000 $1377.6600 $459.2200
SENS -V5264 EARMOLD 7 8 9.100000 $164.9800 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 88 92 535.614294 $43556.1300 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 11 11 45.266669 $3681.0900 $81.3200
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 7 7 37.428572 $2437.3400 $65.1200
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 1 1 7.714286 $502.3600 $65.1200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 7 7 65.390476 $5317.5500 $81.3200
SPL -92507TLGTHM SPL THERAPY SESSION BY SLP ASST 2 3 5.476190 $356.6100 $65.1200
SPL -92508HA GROUP SPL SESSION PER CHILD 2 2 12.000000 $189.1200 $15.7600
TRAN -TRAN *FAMILY TRANSPORTATION 1 1 4.142857 $414.2900 $100.0000
TRAV -TRAVS Travel by mile 1189 1639 8667.562804 $3857.0700 $0.4500
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Subtotal (Total Children Is Unduplicated) 1383 6333 28505.118480 $941954.3300 $33.0500
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Total 8132 31700.538779 $1158839.1600 $36.5600
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Number of Children (Unduplicated) With at Least One Authorization 1690