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: 01-01-25 and 03-31-25 Date of Report: 04-06-25 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1983 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 6.012699 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 6.012699 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 37 38 30.458948 $1477.2500 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 5 5 3.172603 $195.7800 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 2 2 1.388889 $21.1000 $15.1900
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 2.000000 $48.5600 $24.2800
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.005479 $0.2500 $45.5000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.8100 $115.8100
EXIT -EXIT COS Exit 13 13 9.010960 $450.5400 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 4 8.000000 $600.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $161.9600 $80.9800
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 6 6 12.000000 $971.7600 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 7 7 14.000000 $838.8800 $59.9200
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 94 95 147.609580 $11953.4600 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 26 26 51.000000 $4129.9800 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 51 54 105.000000 $8502.9000 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 21 22 44.000000 $3563.1200 $80.9800
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 1 1 2.000000 $161.9600 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 140 142 237.109580 $14207.6300 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 38 38 75.000000 $4494.0000 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 61 92 183.000000 $14819.3400 $80.9800
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 8 9 18.500000 $1498.1300 $80.9800
OCTF -97168 OT RE-EVAL EST PLAN CARE 2 2 0.452055 $26.2700 $58.1200
OCTF -97168GT OT RE-EVAL EST PLAN CARE 1 1 0.189041 $10.9800 $58.1000
OCTH -97165 OT EVAL LOW COMPLEXITY 41 41 29.635235 $1722.1000 $58.1100
OCTH -97165GT OT EVAL LOW COMPLEXITY 2 2 5.033333 $292.4900 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 20 20 9.388965 $545.5900 $58.1100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 2 0.331507 $19.2600 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 18 18 10.042389 $583.5600 $58.1100
PSTH -97161GT PT EVAL LOW COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 6 6 3.254795 $189.1400 $58.1100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 3 3 1.199392 $69.7000 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 42 44 28.210426 $1639.3100 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 1.000000 $58.1100 $58.1100
SPCH -92522 EVAL OF SPCH SOUND PROD 12 14 14.060807 $817.0700 $58.1100
SPCH -92522GT EVAL OF SPCH SOUND PROD 2 2 0.367123 $21.3300 $58.1100
SPCH -92522TL EVAL OF SPCH SOUND PROD 1 1 1.000000 $58.1100 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 18 18 25.803523 $1499.4500 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 0.700000 $40.6800 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 8.857143 $514.6900 $58.1100
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Subtotal (Total Children Is Unduplicated) 391 742 1091.781773 $76672.5200 $70.2300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 39 40 85.573223 $427866.0000 $5000.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.153425 $10.6400 $69.3400
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 49 51 51.602589 $2580.1300 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 22 23 22.358334 $1117.9200 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 190 212 301.780958 $15089.0800 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 2 2 3.866666 $193.3300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.966667 $49.1700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 115 123 167.423813 $8371.2100 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 2 2 3.133333 $156.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.066667 $51.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 3.433334 $171.6700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 2.733334 $68.3400 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 173 178 256.890481 $12844.5500 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 2 2 3.333333 $166.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 3.100000 $77.5000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 184 194 1147.176181 $61947.5300 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 16 16 75.857140 $4096.3000 $54.0000
INTR -T1013 INTERPRETER 28 40 100.714286 $5035.7100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 29 55 207.509523 $2490.1200 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 81 83 514.485710 $41837.9800 $81.3200
OCCT -97530GO OT SESSION BY LICENSED OT 1 1 6.000000 $487.9200 $81.3200
OCCT -97530GOGT OT SESSION BY LICENSED OT 1 1 2.700000 $219.5600 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 31 31 198.021428 $16103.1200 $81.3200
PHY -97110HM PT SESSION BY PT ASST 5 5 42.571428 $2772.2600 $65.1200
SENS -V5060 BEHIND EAR HEARING AID 1 1 0.005479 $1.2600 $230.5000
SENS -V5264 EARMOLD 1 1 0.008219 $0.1500 $18.0900
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 93 98 609.784635 $49587.7000 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 4 14.857143 $1208.1800 $81.3200
TRAV -TRAVS Travel by mile 35 67 5655.242860 $2516.5800 $0.4500
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Subtotal (Total Children Is Unduplicated) 320 1239 9484.350189 $657118.8800 $69.2800
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Total 1983 10582.144661 $733791.4000 $69.3400
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Number of Children (Unduplicated) With at Least One Authorization 535