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: 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 2125 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 6 6 12.519047 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 6 6 12.519047 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 47 47 38.463665 $1865.5000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 4 4 3.002740 $185.3000 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 0.283333 $4.3000 $15.1900
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 2.000000 $48.5600 $24.2800
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.000000 $23.1400 $23.1400
AUDE -92651 AEP HEARING STATUS DETER I&R 1 1 1.000000 $78.2500 $78.2500
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.355556 $41.1800 $115.8200
EXIT -EXIT COS Exit 3 3 2.002740 $100.1400 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 4.005479 $324.3700 $80.9800
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 1 1 2.000000 $161.9600 $80.9800
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 4.000000 $323.9200 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 2.005479 $120.1700 $59.9200
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 2 2 4.000000 $239.6800 $59.9200
IPDEF -T1024TSTL F/U PSYCH AND DEV EVAL BY EI PROF 2 2 4.000000 $323.9200 $80.9800
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 81 83 127.104101 $10292.9200 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 24 24 47.000000 $3806.0600 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 58 61 119.500000 $9677.1100 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 14 14 28.000000 $2267.4400 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 121 131 222.604101 $13338.4600 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 47 48 95.000000 $5692.4000 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 86 112 222.000000 $17977.5600 $80.9800
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 32 48 96.000000 $7774.0800 $80.9800
OCTF -97168 OT RE-EVAL EST PLAN CARE 3 3 0.298630 $17.3600 $58.1200
OCTH -97165 OT EVAL LOW COMPLEXITY 45 46 25.428941 $1477.6700 $58.1100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 21 21 12.306010 $715.1000 $58.1100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 5 5 1.846347 $107.2900 $58.1100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 2 2 0.688889 $40.0300 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 2 0.202740 $11.7800 $58.1300
PSTH -97161 PT EVAL LOW COMPLEXITY 33 34 17.067048 $991.7700 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 11 11 6.421081 $373.1300 $58.1100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 2 2 1.505556 $87.4900 $58.1100
PSTH -97162TLGT PT EVAL MODERATE COMPLEXITY 1 1 0.394444 $22.9200 $58.1000
SPCH -92521 EVAL OF SPEECH FLUENCY 48 49 30.901172 $1795.6600 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 2 2 0.244444 $14.2000 $58.1000
SPCH -92521TLGT EVAL OF SPEECH FLUENCY 1 1 0.505556 $29.3800 $58.1200
SPCH -92522 EVAL OF SPCH SOUND PROD 6 6 9.250487 $537.5500 $58.1100
SPCH -92522GT EVAL OF SPCH SOUND PROD 4 4 1.727549 $100.3900 $58.1100
SPCH -92522TL EVAL OF SPCH SOUND PROD 2 2 1.082192 $62.8900 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 11 12 10.326027 $600.0400 $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 2 2 1.033333 $60.0500 $58.1100
SPCH -92610GT EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 0.450000 $26.1500 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 1.571429 $91.3100 $58.1100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 1 0.388889 $22.6000 $58.1100
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Subtotal (Total Children Is Unduplicated) 404 806 1152.967958 $82083.6200 $71.1900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 48 48 130.740877 $653704.5000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 55 57 75.431680 $3771.5700 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 16 16 21.505556 $1075.2800 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 216 245 406.400000 $20319.9900 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 3 4 4.333333 $216.6700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 3 4.999999 $125.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 132 137 205.085713 $10254.2800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 4 4 2.233332 $111.6600 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 1 1 0.366667 $18.3400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 5.700000 $142.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 179 185 275.461906 $13773.1000 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 1 1 0.366667 $18.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 4 7.395238 $184.8800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 214 230 1506.299993 $81340.1900 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 22 24 112.857141 $6094.2900 $54.0000
INTR -T1013 INTERPRETER 26 38 81.035714 $4051.7900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 10 13 32.166667 $386.0000 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 97 99 648.338091 $52722.8500 $81.3200
OCCT -97530GO OT SESSION BY LICENSED OT 2 2 10.857143 $882.9000 $81.3200
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 5.285714 $429.8300 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 54 54 343.857142 $27962.4700 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 2 2 11.571429 $940.9900 $81.3200
PHY -97110HM PT SESSION BY PT ASST 7 7 41.857142 $2725.7400 $65.1200
SENS -V5060 BEHIND EAR HEARING AID 1 1 0.355556 $81.6500 $229.6400
SENS -V5264 EARMOLD 1 1 0.355556 $6.4500 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 89 92 585.947354 $47649.2400 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 6 6 40.571428 $3299.2700 $81.3200
TRAV -TRAVS Travel by mile 20 36 3438.395237 $1530.0900 $0.4500
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Subtotal (Total Children Is Unduplicated) 358 1313 7999.772275 $933819.8100 $116.7300
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Total 2125 9165.259280 $1015903.4400 $110.8400
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Number of Children (Unduplicated) With at Least One Authorization 594