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: 10-01-24 and 12-31-24 Date of Report: 03-31-25 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2728 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 39 40 2969.322222 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 48 48 12508.944445 $465332.7400 $37.2000
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Subtotal (Total Children Is Unduplicated) 87 88 15478.266667 $465332.7400 $30.0600
Screening, Eval, and Assessment, Class # 02
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 0.088889 $1.3500 $15.1900
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.088889 $0.7000 $7.9200
EXIT -EXIT COS Exit 1 1 1.000000 $50.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 9 10 13.337748 $1000.3400 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 43 43 75.101675 $6081.7400 $80.9800
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 4 4 7.000000 $566.8600 $80.9800
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 1 1 2.000000 $161.9600 $80.9800
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 10 10 20.000000 $1619.6000 $80.9800
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 1 1 2.000000 $161.9600 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 27 29 45.602132 $2732.4800 $59.9200
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 4 4 6.377778 $382.1600 $59.9200
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 297 301 600.000000 $48588.0000 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 42 44 88.000000 $7126.2400 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 38 38 76.000000 $6154.4800 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 17 17 34.000000 $2753.3200 $80.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 95 95 190.000000 $15386.2000 $80.9800
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 8 8 16.000000 $1295.6800 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 154 154 307.000000 $18395.4400 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 16 16 32.000000 $1917.4400 $59.9200
OCTF -97168 OT RE-EVAL EST PLAN CARE 52 54 26.042065 $1513.3100 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 1.172222 $68.1200 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 0.522222 $30.3500 $58.1100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 43 44 41.750806 $2426.1400 $58.1100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 3 3 0.611111 $35.5100 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 21 21 6.057384 $352.0100 $58.1100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 0.344444 $20.0100 $58.1000
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.172222 $10.0100 $58.1000
PSTH -97162 PT EVAL MODERATE COMPLEXITY 6 7 4.666667 $271.1800 $58.1100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 2 2 1.477778 $85.8800 $58.1100
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 15 16 15.255175 $886.4800 $58.1100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.500000 $7.5600 $15.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 16 16 9.861112 $573.0300 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 110 114 35.389879 $2056.5100 $58.1100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.566667 $91.0400 $58.1100
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 1.000000 $58.1100 $58.1100
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Subtotal (Total Children Is Unduplicated) 613 1070 1666.986865 $123151.7400 $73.8800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 2.044444 $10222.0000 $4999.8900
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 0.516667 $119.6800 $231.6300
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 20 22 17.993652 $899.6900 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 2 2 2.000000 $100.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 7 7 4.083333 $102.0800 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 197 205 106.605555 $5330.2800 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 1 1 0.411111 $20.5600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 122 126 133.361109 $3334.0200 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 91 156 78.465077 $3923.2500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 33 63 69.461111 $1736.5300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 28 55 29.244445 $1462.2300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 14 28 40.522223 $1013.0600 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 172 179 96.805553 $4840.2700 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 1 2 0.055556 $2.7800 $50.0400
CONSP -CONSP CONSULT, SLP, PHONE 119 126 129.972222 $3249.3100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 223 233 1491.309535 $80530.7100 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 5 5 28.857144 $1558.2800 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 67 71 481.142862 $39126.5300 $81.3200
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 2.285714 $185.8700 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 63 68 537.071425 $34974.1000 $65.1200
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 12.714286 $827.9600 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 32 32 188.000001 $15288.1600 $81.3200
PHY -97110HM PT SESSION BY PT ASST 33 35 258.035715 $16803.2800 $65.1200
PHY -97110HMGT PT SESSION BY PT ASST 1 1 6.428571 $418.6300 $65.1200
SENS -V5060 BEHIND EAR HEARING AID 1 1 0.008219 $1.8800 $229.0800
SENS -V5264 EARMOLD 2 2 0.516667 $9.3700 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 121 128 752.785720 $61216.5300 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 6 6 28.357143 $2306.0000 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 8 8 59.785714 $4861.7700 $81.3200
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Subtotal (Total Children Is Unduplicated) 459 1570 4558.840774 $294464.7900 $64.5900
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Total 2728 21704.094306 $882949.2600 $40.6800
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Number of Children (Unduplicated) With at Least One Authorization 879