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 1009 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 28 28 27.259861 $1322.1100 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 3 3 2.002740 $123.5900 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 0.283333 $4.3000 $15.1900
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.000000 $24.2800 $24.2800
AUDE -92651 AEP HEARING STATUS DETER I&R 1 1 1.000000 $78.2500 $78.2500
EXIT -EXIT COS Exit 2 2 1.002740 $50.1400 $50.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $119.8400 $59.9200
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 12 12 10.038353 $812.9200 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 4 4 8.000000 $647.8400 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 10 10 19.500000 $1579.1100 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 5 5 10.000000 $809.8000 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 26 26 38.038353 $2279.2700 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 10 10 20.000000 $1198.4000 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 28 38 75.000000 $6073.5000 $80.9800
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 14 22 44.000000 $3563.1200 $80.9800
OCTH -97165 OT EVAL LOW COMPLEXITY 6 6 2.538356 $147.5100 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.233333 $13.5600 $58.1000
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 0.002740 $0.1600 $57.2600
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 3 3 1.516667 $88.1400 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.002740 $0.1600 $57.2600
SPCH -92521 EVAL OF SPEECH FLUENCY 4 4 1.441629 $83.7700 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 0.233333 $13.5600 $58.1000
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 8.428571 $489.7900 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $58.1100 $58.1100
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Subtotal (Total Children Is Unduplicated) 111 184 275.522749 $19639.3000 $71.2800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 6 4.545597 $22728.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 55 57 75.431680 $3771.5700 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 13 13 16.005556 $800.2800 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 214 243 402.200000 $20109.9900 $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 127 132 195.352380 $9767.6100 $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 174 180 265.928573 $13296.4300 $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 54 59 367.652378 $19853.2300 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 3 3 -13.285714 $-717.4300 $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 9 9 42.571428 $3461.9100 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 3 3 12.857142 $1045.5500 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 8 8 36.018786 $2929.0500 $81.3200
TRAV -TRAVS Travel by mile 20 36 3438.395237 $1530.0900 $0.4500
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Subtotal (Total Children Is Unduplicated) 294 819 4982.270660 $103831.4200 $20.8400
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Total 1009 5270.312456 $123470.7300 $23.4300
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Number of Children (Unduplicated) With at Least One Authorization 375