Summary Report for FSPSAs Ending During the Report Period Center: 01
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: 04-01-25 and 06-30-25 Date of Report: 07-19-25 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 5045 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 67 70 50.661110 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 67 70 50.661110 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 30 31 23.295740 $1129.8500 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 5 5 5.000000 $308.5500 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 1.000000 $15.1900 $15.1900
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 1.733333 $13.7300 $7.9200
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 2 2 1.888889 $153.4500 $81.2400
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.266667 $30.8900 $115.8200
EXIT -EXIT COS Exit 117 129 110.583759 $5529.1800 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 3 5 10.000000 $750.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $161.9600 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 4.000000 $239.6800 $59.9200
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 9 9 17.000000 $1376.6600 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 6 6 11.000000 $890.7800 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 3 3 6.000000 $485.8800 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 1 1 1.500000 $121.4700 $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 28 31 61.000000 $3655.1200 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 11 11 19.000000 $1138.4800 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 22 30 60.000000 $4858.8000 $80.9800
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 6 9 18.000000 $1457.6400 $80.9800
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 3 3 3.000000 $174.3300 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 2 2 14.857143 $863.3500 $58.1100
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Subtotal (Total Children Is Unduplicated) 214 296 389.625531 $24784.5100 $63.6100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 12 13 10.401218 $52006.5000 $5000.0400
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 2.000000 $463.2400 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 338 382 383.749840 $19187.5000 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 88 99 84.550688 $4227.5200 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 42 42 36.704110 $917.6000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 243 257 434.132534 $21706.5900 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 29 29 47.119046 $2355.9500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 9 9 10.733333 $268.3300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 86 90 140.685715 $7034.2900 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 18 18 31.147618 $1557.3800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 5 5 6.166666 $154.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 102 108 178.383333 $8919.1700 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 9 9 10.199999 $510.0000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.500000 $37.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 130 136 206.012695 $10300.6200 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 16 16 33.133333 $1656.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 7 7 15.699999 $392.5000 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 3 3 19.000001 $950.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 83 85 484.803168 $26179.3600 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 19 20 133.980951 $7234.9900 $54.0000
INTR -T1013 INTERPRETER 245 300 499.183333 $24959.1800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1116 1468 8090.746313 $97089.0000 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 6 6 28.152381 $2289.3600 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 13 13 95.095238 $7733.1300 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 2 2 13.219047 $1074.9700 $81.3200
PHY -97110TLGT PT SESSION BY LICENSED PT 1 1 1.428571 $116.1700 $81.3200
SENS -V5060 BEHIND EAR HEARING AID 1 1 0.266667 $61.2400 $229.6400
SENS -V5264 EARMOLD 1 1 0.266667 $4.8400 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 17 17 124.285713 $10106.9100 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 4 4 13.895238 $1129.9700 $81.3200
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 2.985714 $194.4300 $65.1200
SPL -92508HA GROUP SPL SESSION PER CHILD 1 1 13.000000 $204.8800 $15.7600
TRAV -TRAVS Travel by mile 1176 1532 8195.884412 $3647.1600 $0.4400
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Subtotal (Total Children Is Unduplicated) 1434 4679 19348.513541 $314671.0800 $16.2600
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Total 5045 19788.800182 $339455.5900 $17.1500
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Number of Children (Unduplicated) With at Least One Authorization 1537