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 5359 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 73 75 40.033335 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 73 75 40.033335 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 37 38 40.386150 $1958.7300 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 3 3 4.571429 $282.1000 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 3 4 6.000000 $91.1400 $15.1900
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.000000 $24.2800 $24.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.000000 $7.9200 $7.9200
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 4 4 4.000000 $181.2800 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.8100 $115.8100
EXIT -EXIT COS Exit 111 124 108.080692 $5404.0300 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 3 5 10.000000 $750.0000 $75.0000
IPDEF -IPDEF_NM F/U PSYCH & DEV EVAL BY NON-MED PRO 1 1 2.000000 $111.0000 $55.5000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 3 6.000000 $359.5200 $59.9200
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 9 11 22.000000 $1781.5600 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 9 9 13.000000 $1052.7400 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 7 7 14.000000 $1133.7200 $80.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 4 4 8.000000 $647.8400 $80.9800
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 5 5 7.500000 $607.3500 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 29 31 62.000000 $3715.0400 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 13 14 23.500000 $1408.1200 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 22 25 50.000000 $4049.0000 $80.9800
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 5 8 15.000000 $1214.7000 $80.9800
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 1.000000 $58.1100 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.922222 $13.9300 $15.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 2.000000 $116.2200 $58.1100
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Subtotal (Total Children Is Unduplicated) 225 309 408.404937 $25407.5900 $62.2100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 15 15 19.336986 $96685.0000 $5000.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.383333 $95.9300 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 2.000000 $463.2400 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 409 453 500.674041 $25033.6900 $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 245 274 523.775391 $26188.7400 $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 93 101 157.422214 $7871.0700 $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 137 143 270.870633 $13543.5200 $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 91 93 564.603182 $30488.5600 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 17 20 89.609526 $4838.9000 $54.0000
INTR -T1013 INTERPRETER 195 250 414.071429 $20703.5700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1147 1537 8532.696137 $102392.3200 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 8 9 49.666668 $4038.9000 $81.3200
OCCT -97530GO OT SESSION BY LICENSED OT 1 1 1.733333 $140.9500 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 19 20 152.857145 $12430.3400 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 3 3 6.314286 $513.4800 $81.3200
SENS -V5060 BEHIND EAR HEARING AID 1 1 1.000000 $229.6100 $229.6100
SENS -V5264 EARMOLD 3 4 6.766667 $122.6800 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 20 20 115.595241 $9400.2000 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 11.314286 $920.0800 $81.3200
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 9.285714 $604.6800 $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 1 1 34.285714 $2788.1100 $81.3200
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 1638 8660.562804 $3853.9600 $0.4500
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Subtotal (Total Children Is Unduplicated) 1355 4975 20693.747207 $389352.1700 $18.8100
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Total 5359 21142.185479 $414759.7600 $19.6200
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Number of Children (Unduplicated) With at Least One Authorization 1499