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: 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 905 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 3 3 9.063492 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 9.063492 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 15 15 10.535161 $510.9600 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 3 3 1.380518 $85.1900 $61.7100
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.000000 $16.1500 $16.1500
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.000000 $24.2800 $24.2800
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.377778 $43.7500 $115.8200
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 3 3 6.000000 $485.8800 $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 9 9 18.000000 $1078.5600 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 27 37 73.000000 $5911.5400 $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 3 3 2.210959 $128.4800 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.272222 $15.8200 $58.1100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 0.002740 $0.1600 $57.2600
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.105556 $6.1400 $58.1300
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.002740 $0.1600 $57.2600
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 0.083333 $4.8400 $58.0900
SPCH -92521 EVAL OF SPEECH FLUENCY 4 4 2.352740 $136.7200 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 0.272222 $15.8200 $58.1100
SPCH -92521TLGT EVAL OF SPEECH FLUENCY 1 1 1.142857 $66.4100 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $58.1100 $58.1100
SPCH -92610GT EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.083333 $4.8400 $58.0900
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Subtotal (Total Children Is Unduplicated) 87 164 243.401605 $17807.9900 $73.1600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 7 7 14.515003 $72575.5000 $5000.0300
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 70 72 91.831680 $4591.5800 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 13 14 16.938889 $846.9500 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 191 216 311.871425 $15593.5600 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 4 4 9.066666 $453.3300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 2 2.666666 $66.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 110 113 166.790478 $8339.5300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 9 10 6.099998 $304.9900 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 1 1 2.633333 $131.6700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.033333 $0.8300 $24.9800
CONSF -CONSF CONSULT, SLP, FACE TO FACE 165 168 258.504764 $12925.2500 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 2 2 5.366666 $268.3300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 3.200000 $80.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 31 33 193.719048 $10460.8500 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 5 5 30.428572 $1643.1400 $54.0000
INTR -T1013 INTERPRETER 26 38 75.464286 $3773.2200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3 3 3.000000 $36.0000 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 6 6 35.000000 $2846.2100 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 3 3 13.571429 $1103.6300 $81.3200
PHY -97110GPGT PT SESSION BY LICENSED PT 1 1 2.142857 $174.2600 $81.3200
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.377778 $86.7500 $229.6200
SENS -V5264 EARMOLD 1 1 1.133333 $20.5500 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 6 6 34.714286 $2822.9700 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 3.285714 $267.2000 $81.3200
TRAV -TRAVS Travel by mile 13 26 1542.285714 $686.3200 $0.4500
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Subtotal (Total Children Is Unduplicated) 271 738 2824.641918 $140099.2500 $49.6000
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Total 905 3077.107015 $157907.2300 $51.3200
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Number of Children (Unduplicated) With at Least One Authorization 323