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: 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 795 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 7 7 20.030954 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 7 7 20.030954 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 8 8 8.000000 $388.0000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 2.000000 $123.4200 $61.7100
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.041096 $0.6600 $16.1500
EXIT -EXIT COS Exit 12 12 9.974962 $498.7500 $50.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $119.8400 $59.9200
IPDEF -T1024TSTL F/U PSYCH AND DEV EVAL BY EI PROF 2 3 6.000000 $485.8800 $80.9800
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 5 6 8.010958 $648.7300 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $161.9600 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 4 4 8.000000 $647.8400 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 2 2 4.000000 $323.9200 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 25 26 48.010958 $2876.8200 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 6 6 12.000000 $719.0400 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 21 25 50.000000 $4049.0000 $80.9800
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 9 14 28.000000 $2267.4400 $80.9800
OCTH -97165 OT EVAL LOW COMPLEXITY 3 3 3.000000 $174.3300 $58.1100
OCTH -97165TLGT OT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.122222 $7.1000 $58.1000
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 1.210959 $70.3700 $58.1100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 0.122222 $7.1000 $58.1000
SPCH -92521 EVAL OF SPEECH FLUENCY 4 4 1.636910 $95.1200 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.166667 $67.8000 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.122222 $7.1000 $58.1000
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Subtotal (Total Children Is Unduplicated) 77 128 198.419176 $13914.5500 $70.1300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 52 54 59.622720 $2981.1300 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 14 16 20.500000 $1025.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 2.136073 $53.4000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 186 199 316.509528 $15825.5000 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 2 2 2.766667 $138.3400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 88 91 136.500000 $6825.0000 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 1 1 0.750000 $37.5000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 5.133334 $128.3400 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 17 17 22.400002 $1120.0100 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 2 2 4.466667 $223.3400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 8 8 9.866668 $246.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 150 150 230.696034 $11534.8200 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 1 1 2.766667 $138.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 4.633334 $115.8400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 35 36 162.576188 $8779.1300 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 7 7 12.714285 $686.5700 $54.0000
INTR -T1013 INTERPRETER 25 39 84.500000 $4225.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 5 5 -63.857144 $-5192.8600 $81.3200
OCCT -97530GOGT OT SESSION BY LICENSED OT 1 1 3.071429 $249.7700 $81.3200
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 0.122222 $9.9400 $81.3100
PHY -97110 PT SESSION BY LICENSED PT 3 3 25.000000 $2033.0000 $81.3200
PHY -97110GP PT SESSION BY LICENSED PT 1 1 6.142857 $499.5400 $81.3200
PHY -97110GPGT PT SESSION BY LICENSED PT 2 2 10.428571 $848.0500 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 6 6 31.142856 $2532.5300 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 3.142857 $255.5800 $81.3200
TRAV -TRAVS Travel by mile 5 10 600.000000 $267.0000 $0.4500
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Subtotal (Total Children Is Unduplicated) 258 660 1694.731815 $60586.4400 $35.7500
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Total 795 1913.181945 $74500.9900 $38.9400
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Number of Children (Unduplicated) With at Least One Authorization 297