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: 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 2856 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 53 53 1544.120635 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 47 47 13776.388888 $512481.6600 $37.2000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 100 100 15320.509523 $512481.6600 $33.4500
Screening, Eval, and Assessment, Class # 02
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 2.000000 $15.8400 $7.9200
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 2.000000 $63.6200 $31.8100
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 5 5 4.230528 $317.3000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 56 57 104.285693 $8445.0600 $80.9800
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 11 11 17.087671 $1383.7600 $80.9800
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 9 9 15.000000 $1214.7000 $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 16 16 32.000000 $2591.3600 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 22 22 37.043835 $2219.6600 $59.9200
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 6 7 14.000000 $838.8800 $59.9200
IPDEF -T1024TSTL F/U PSYCH AND DEV EVAL BY EI PROF 1 1 0.317808 $25.7400 $80.9800
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 320 320 634.571428 $51387.5900 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 46 47 94.000000 $7612.1200 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 71 71 142.000000 $11499.1600 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 14 14 26.066667 $2110.8800 $80.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 113 113 224.285714 $18162.6600 $80.9800
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 11 11 22.000000 $1781.5600 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 125 125 250.000000 $14980.0000 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 51 51 100.285714 $6009.1200 $59.9200
OCTF -97168 OT RE-EVAL EST PLAN CARE 63 64 23.237302 $1350.3300 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 0.638889 $37.1300 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 3 3 1.661111 $96.5300 $58.1100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 51 52 43.422223 $2523.2700 $58.1100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 3 3 3.000000 $174.3300 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 35 36 10.099619 $586.8900 $58.1100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 2 2 0.261111 $15.1700 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 5 5 3.777778 $219.5300 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 12 12 8.927777 $518.7900 $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 0.488889 $7.3900 $15.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 13 13 5.183334 $301.2100 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 0.411111 $23.8900 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 98 103 75.978241 $4415.0800 $58.1100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 2.111111 $122.6800 $58.1100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 3.133333 $182.0800 $58.1100
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 1.000000 $58.1100 $58.1100
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 684 1188 1908.506887 $141569.5700 $74.1800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.000000 $10000.0000 $5000.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.488889 $113.2400 $231.6300
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 8 11 9.500000 $475.0000 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 4 5 4.000000 $200.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 5 5 3.133333 $78.3300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 200 212 110.643651 $5532.1800 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 2 2 0.822223 $41.1200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 140 146 145.064287 $3626.6100 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 86 146 75.583329 $3779.1500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 36 69 72.320637 $1808.0200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 23 42 19.822220 $991.1000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 7 13 14.822222 $370.5600 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 175 185 94.121428 $4706.0700 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 1 1 0.255556 $12.7800 $50.0100
CONSP -CONSP CONSULT, SLP, PHONE 135 143 142.980952 $3574.5200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 221 232 1480.928566 $79970.1700 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 14 16 83.428572 $4505.1300 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 46 46 292.052375 $23749.7100 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 63 69 489.714281 $31890.2000 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 29 31 196.714284 $15996.8200 $81.3200
PHY -97110HM PT SESSION BY PT ASST 38 40 250.230954 $16295.0400 $65.1200
PHY -97110HMGT PT SESSION BY PT ASST 2 2 8.857143 $576.7700 $65.1200
SENS -V5264 EARMOLD 2 2 1.488889 $26.9900 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 120 128 757.499994 $61599.9200 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 6 7 62.428572 $5076.6800 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 10 10 50.657142 $4119.4400 $81.3200
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 2 1.000000 $81.3200 $81.3200
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 481 1568 4370.559499 $279196.8500 $63.8800
-------------------------------------------------------------------------------------------------------------------------------------
Total 2856 21599.575909 $933248.0900 $43.2100
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 960