Summary Report for FSPSAs Initiated During the Report Period Center: 01
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: 10-01-25 and 12-31-25 Date of Report: 01-07-26 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 4589 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 74 75 64.389682 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 74 75 64.389682 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 22 23 15.832877 $767.9000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 7.000000 $431.9700 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 3 3 4.000000 $60.7600 $15.1900
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.000000 $24.2800 $24.2800
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 7.571429 $175.2000 $23.1400
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 1 1 0.277778 $22.5700 $81.2500
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.3200 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.277778 $32.1700 $115.8200
EXIT -EXIT COS Exit 174 179 154.907926 $7745.4000 $50.0000
IPDEF -T1024TSTL F/U PSYCH AND DEV EVAL BY EI PROF 1 2 4.000000 $323.9200 $80.9800
IPDEF -T1024TSTLGT F/U PHYC AND DEV EVAL BY EI PROF 1 2 4.000000 $323.9200 $80.9800
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 2 2 4.000000 $323.9200 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 2 2 3.500000 $283.4300 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.000000 $161.9600 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.000000 $161.9600 $80.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 3 3 6.000000 $485.8800 $80.9800
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 1 2 4.000000 $323.9200 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 20 21 42.000000 $2516.6400 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 7 8 16.000000 $958.7200 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 16 20 41.000000 $3320.1800 $80.9800
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 12 17 33.500000 $2712.8300 $80.9800
OCTH -97165 OT EVAL LOW COMPLEXITY 4 5 5.000000 $290.5500 $58.1100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 1.000000 $58.1100 $58.1100
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.233333 $3.5300 $15.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 2.000000 $116.2200 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 1.000000 $58.1100 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 2.000000 $116.2200 $58.1100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 1 2.714286 $157.7300 $58.1100
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Subtotal (Total Children Is Unduplicated) 248 307 368.815407 $22061.4200 $59.8200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 9 9 5.460274 $27301.5000 $5000.0200
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.350000 $24.2700 $69.3500
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 353 390 421.524414 $21076.2200 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 91 102 80.889502 $4044.4500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 45 45 42.278931 $1056.9800 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 202 231 403.132812 $20156.6600 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 23 27 43.933333 $2196.6700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 7 7 13.700000 $342.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 53 54 149.534129 $7476.7200 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 10 10 17.766666 $888.3300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 4 4 11.033333 $275.8300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 79 80 129.673290 $6483.6800 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 7 8 12.233333 $611.6700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 2.933333 $73.3300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 113 115 236.275395 $11813.7700 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 9 10 16.233333 $811.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 7 8 34.057143 $851.4300 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 4 4 20.933333 $1046.6700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 53 56 343.371425 $18542.0700 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 19 20 162.285713 $8763.4300 $54.0000
INTR -T1013 INTERPRETER 218 297 450.266666 $22513.3400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1022 1308 8043.842241 $96526.1500 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 4 4 19.152381 $1557.4800 $81.3200
OCCT -97530TLGTHM OT SESSION BY OT ASST 1 1 12.142857 $790.7500 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 14 14 92.533334 $7524.8100 $81.3200
SENS -V5060 BEHIND EAR HEARING AID 1 1 0.277778 $63.7900 $229.6300
SENS -V5264 EARMOLD 3 3 2.977778 $53.9900 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 21 22 151.038094 $12282.4200 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 2.000000 $162.6400 $81.3200
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 2.714286 $220.7300 $81.3200
TRAV -TRAVS Travel by mile 1045 1372 8185.447002 $3642.5200 $0.4400
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Subtotal (Total Children Is Unduplicated) 1230 4207 19109.992109 $279176.4100 $14.6100
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Total 4589 19543.197198 $301237.8300 $15.4100
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Number of Children (Unduplicated) With at Least One Authorization 1430