Summary Report for FSPSAs Ending During the Report Period Center: 55
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: 07-01-24 and 09-30-24 Date of Report: 04-06-25 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2706 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 35 36 1235.603174 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 42 42 9797.153969 $364454.1300 $37.2000
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Subtotal (Total Children Is Unduplicated) 77 78 11032.757143 $364454.1300 $33.0300
Screening, Eval, and Assessment, Class # 02
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.261111 $2.0700 $7.9200
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.261111 $3.9700 $15.1900
EXIT -EXIT COS Exit 4 4 4.000000 $200.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 8 12 22.011111 $1650.8300 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 38 40 70.287670 $5691.8900 $80.9800
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 6 6 8.392846 $679.6600 $80.9800
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 5 5 8.011111 $648.7400 $80.9800
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 2 2 4.000000 $323.9200 $80.9800
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 14 14 28.000000 $2267.4400 $80.9800
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 2 2 4.000000 $323.9200 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 18 18 33.105556 $1983.6900 $59.9200
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 2 2 0.180821 $10.8300 $59.9100
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 268 271 540.066667 $43734.6000 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 49 52 102.266667 $8281.5600 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 61 61 122.000000 $9879.5600 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 12 12 24.000000 $1943.5200 $80.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 63 63 124.066667 $10046.9200 $80.9800
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 15 15 30.000000 $2429.4000 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 144 144 288.000000 $17256.9600 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 27 27 54.000000 $3235.6800 $59.9200
OCTF -97168 OT RE-EVAL EST PLAN CARE 53 54 16.933335 $984.0100 $58.1100
OCTF -97168GT OT RE-EVAL EST PLAN CARE 1 1 0.383333 $22.2700 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 3 3 2.084932 $121.1500 $58.1100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 5 5 1.349999 $78.4400 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 65 65 58.134931 $3378.2100 $58.1100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 3 3 2.177778 $126.5500 $58.1100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 34 36 24.007959 $1395.1000 $58.1100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 0.177778 $10.3300 $58.1200
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.138889 $8.0700 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 5 6 4.416666 $256.6500 $58.1100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 17 17 14.222221 $826.4500 $58.1100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.241096 $3.6400 $15.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 20 23 6.372224 $370.3000 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 2 2 2.155556 $125.2600 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 118 125 49.106120 $2853.5600 $58.1100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 0.227778 $13.2400 $58.1200
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 0.388889 $22.6000 $58.1100
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Subtotal (Total Children Is Unduplicated) 630 1102 1653.430822 $121423.4400 $73.4400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 9 9 8.388889 $41944.5000 $5000.0100
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 0.955555 $221.3100 $231.6100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 22 27 14.131750 $706.6100 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 2 2 1.500000 $75.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 11 11 5.766667 $144.1700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 161 175 107.329365 $5366.4700 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 4 4 1.200000 $60.0000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 89 95 93.022219 $2325.5500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 100 167 85.865870 $4293.2800 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 4 5 2.488888 $124.4400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 46 86 89.727777 $2243.1900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 31 57 27.027778 $1351.3900 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 1 1 0.266667 $13.3400 $50.0100
CONPP -CONPP CONSULT, PT, PHONE 13 25 35.961906 $899.0500 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 134 142 78.852379 $3942.6100 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 2 2 0.977778 $48.8900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 87 93 87.144444 $2178.6100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 180 192 1343.128567 $72528.9700 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 8 9 52.000000 $2808.0000 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 73 76 513.999999 $41798.4700 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 80 88 637.642859 $41523.2800 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 38 39 214.448414 $17438.9400 $81.3200
PHY -97110HM PT SESSION BY PT ASST 36 39 256.750000 $16719.5600 $65.1200
PHY -97110HMGT PT SESSION BY PT ASST 1 1 20.571429 $1339.6100 $65.1200
SENS -V5060 BEHIND EAR HEARING AID 3 3 0.591781 $135.8800 $229.6200
SENS -V5264 EARMOLD 4 4 3.188889 $57.8100 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 149 159 996.951608 $81072.0900 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 7.714286 $627.3200 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 8 8 58.466667 $4754.5000 $81.3200
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 2.533333 $206.0100 $81.3200
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Subtotal (Total Children Is Unduplicated) 473 1526 4748.595764 $346948.8500 $73.0600
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Total 2706 17434.783729 $832826.4200 $47.7700
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Number of Children (Unduplicated) With at Least One Authorization 890