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: 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 1984 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 4 4 2.877777 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 4 4 2.877777 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 35 35 20.278463 $983.5100 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 4 4 3.002740 $185.3000 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 0.111111 $1.6900 $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 2 2 3.000000 $347.4300 $115.8100
EXIT -EXIT COS Exit 10 10 6.010960 $300.5400 $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 93 94 145.609580 $11791.5000 $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 139 141 235.109580 $14087.7900 $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
OCTH -97165 OT EVAL LOW COMPLEXITY 45 46 35.690554 $2073.9800 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 25 26 9.958979 $578.7200 $58.1100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 3 3 1.361111 $79.0900 $58.1100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 0.013699 $0.8000 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 20 20 9.120625 $530.0100 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 16 16 7.934550 $461.0800 $58.1100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 2 2 1.344444 $78.1200 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 43 44 25.109285 $1459.1000 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 0.066667 $3.8800 $58.1400
SPCH -92521TLGT EVAL OF SPEECH FLUENCY 1 1 0.372222 $21.6300 $58.1100
SPCH -92522 EVAL OF SPCH SOUND PROD 10 10 2.357002 $136.9700 $58.1100
SPCH -92522GT EVAL OF SPCH SOUND PROD 1 1 1.000000 $58.1100 $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 11 11 12.922506 $750.9300 $58.1100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $58.1100 $58.1100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 3.000000 $174.3300 $58.1100
SPCH -92610GT EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 0.744444 $43.2600 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 9.857143 $572.8000 $58.1100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 1 0.122222 $7.1000 $58.1000
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Subtotal (Total Children Is Unduplicated) 346 746 1057.603366 $74928.8800 $70.8500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 35 35 94.130681 $470655.0000 $5000.0200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 55 57 75.189099 $3759.4600 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 22 23 22.358334 $1117.9200 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 207 224 367.095244 $18354.7800 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 2 2 3.833334 $191.6700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 133 138 230.966666 $11548.3300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 3 3 3.066666 $153.3300 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 1 1 2.300000 $115.0000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 3 4 7.400000 $185.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 195 198 331.895240 $16594.7700 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 2 2 3.300000 $165.0000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.333333 $33.3300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 212 217 1408.061921 $76035.3100 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 13 13 88.285716 $4767.4300 $54.0000
INTR -T1013 INTERPRETER 26 37 75.000000 $3750.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 5 9 13.523809 $162.2800 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 90 91 618.133341 $50266.6000 $81.3200
OCCT -97530GO OT SESSION BY LICENSED OT 3 3 15.285714 $1243.0400 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 35 35 275.142859 $22374.6300 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 3 3 19.142857 $1556.7000 $81.3200
PHY -97110HM PT SESSION BY PT ASST 5 5 35.142858 $2288.5000 $65.1200
SENS -V5060 BEHIND EAR HEARING AID 2 2 0.268493 $61.6500 $229.6200
SENS -V5264 EARMOLD 2 2 0.271233 $4.9200 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 91 92 591.752390 $48121.2900 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 5 6 33.166668 $2697.1200 $81.3200
TRAV -TRAVS Travel by mile 16 31 2182.476191 $971.2000 $0.4500
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Subtotal (Total Children Is Unduplicated) 338 1234 6498.522647 $737174.2600 $113.4400
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Total 1984 7559.003790 $812103.1400 $107.4400
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Number of Children (Unduplicated) With at Least One Authorization 453