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 962 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
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 4 4 2.877777 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 19 19 8.909056 $432.0900 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $61.7100 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 0.111111 $1.6900 $15.1900
EXIT -EXIT COS Exit 8 8 4.010960 $200.5400 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 2 4.000000 $300.0000 $75.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 12 12 20.010958 $1620.4900 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 5 5 10.000000 $809.8000 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 8 8 16.000000 $1295.6800 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 9 9 18.000000 $1457.6400 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 28 29 54.010958 $3236.3400 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 9 9 18.000000 $1078.5600 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 17 24 48.000000 $3887.0400 $80.9800
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 4 4 8.500000 $688.3300 $80.9800
OCTH -97165 OT EVAL LOW COMPLEXITY 4 4 0.765373 $44.4800 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 5 5 0.556163 $32.3300 $58.1200
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.183333 $10.6500 $58.1000
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 0.312328 $18.1500 $58.1200
SPCH -92521 EVAL OF SPEECH FLUENCY 4 4 2.133029 $123.9500 $58.1100
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 0.221918 $12.9000 $58.1300
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.002740 $58.2700 $58.1100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $58.1100 $58.1100
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 87 154 217.727927 $15486.8500 $71.1300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 5 13.430159 $67151.5000 $5000.0500
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 205 222 364.195244 $18209.7800 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 2 2 3.833334 $191.6700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 127 132 220.400000 $11020.0000 $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 192 195 324.061907 $16203.1100 $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 47 51 326.214290 $17615.5600 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 3 3 29.142857 $1573.7100 $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 10 10 53.857144 $4379.6700 $81.3200
OCCT -97530GO OT SESSION BY LICENSED OT 1 1 6.000000 $487.9200 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 4 4 21.000000 $1707.7300 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 10 10 57.714287 $4693.3300 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 1.166667 $94.8800 $81.3200
TRAV -TRAVS Travel by mile 16 31 2182.476191 $971.2000 $0.4500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 283 804 3806.963321 $153741.3700 $40.3800
-------------------------------------------------------------------------------------------------------------------------------------
Total 962 4027.569025 $169228.2200 $42.0200
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 329