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: 07-01-22 and 06-30-23 Date of Report: 07-25-23 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 11505 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 182 200 12963.342854 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 174 185 130879.269842 $4868708.8400 $37.2000
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Subtotal (Total Children Is Unduplicated) 352 385 143842.612696 $4868708.8400 $33.8500
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 4.600000 $89.7500 $19.5100
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 1 1 0.077778 $5.8500 $75.1500
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 2 4.577778 $207.4700 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 3 3.355555 $388.6000 $115.8100
EVAL -96111 DEVELOPMENTAL EVALUATION 117 156 240.913622 $12045.6900 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 22 26 40.036681 $2001.8400 $50.0000
EXIT -EXIT EXIT ASSESSMENT 51 51 91.033333 $4551.6700 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 8 10 19.666667 $1475.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 72 74 142.027701 $10652.0800 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 6 6 12.000000 $900.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 8 8 16.000000 $1200.0000 $75.0000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 37 37 74.000000 $5550.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 5 5 10.000000 $750.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 2.005479 $150.4100 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 27 27 48.977778 $2718.2700 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 1103 1115 2218.133334 $166360.0100 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 259 261 520.000000 $39000.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 202 202 400.066667 $30005.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 60 60 118.000000 $8850.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 301 301 601.000000 $45075.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 66 66 130.000000 $9750.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 648 658 1314.066667 $72930.7000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 145 146 290.000000 $16095.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $150.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 198 281 205.533337 $10566.4900 $51.4100
OCTF -97168GT OT RE-EVAL EST PLAN CARE 5 5 3.166667 $162.8000 $51.4100
OCTF -97168TL OT RE-EVAL EST PLAN CARE 1 1 0.350000 $17.9900 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 11 12 13.566667 $697.4600 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 31 41 25.494446 $1310.6800 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 0.427778 $21.9900 $51.4100
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 227 256 258.227805 $13275.5100 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 17 19 14.222224 $731.1700 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 4 4 6.000000 $308.4600 $51.4100
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 3 4 6.000000 $308.4600 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 110 156 151.321432 $7779.4500 $51.4100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 5 7 5.544445 $285.0400 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 6 6 29.169842 $1499.6200 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 13 22 40.578572 $2086.1500 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 84 98 81.255555 $4177.3500 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 6 6 3.400000 $174.7900 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 3 3 3.000000 $154.2300 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 31 34 29.027779 $1492.3200 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 2 2 2.016667 $103.6800 $51.4100
SPCH -92522TLGT EVAL OF SPCH SOUND PROD 1 1 0.533333 $27.4200 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 374 507 346.119860 $17794.1200 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 4 5 2.694444 $138.5200 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 5 7 3.916667 $201.3600 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.277778 $65.6900 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.272222 $13.9900 $51.4100
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Subtotal (Total Children Is Unduplicated) 2073 4706 7543.656560 $494763.7200 $65.5900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 10 13 10.705555 $53527.5000 $4999.9700
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 6 9 10.311112 $515.5600 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 9 15 20.055557 $4645.3000 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 74 104 71.891677 $3594.6400 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 3 8 8.000000 $400.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 17 20 42.830557 $1070.7700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 495 752 1050.894442 $52544.7100 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 7 7 6.044445 $302.2300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 292 415 1167.311915 $29182.8300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 269 698 839.786500 $41989.2900 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 2 6 9.688888 $484.4400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 116 306 757.972218 $18949.3000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 93 266 354.633328 $17731.6400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 44 136 357.877778 $8946.9500 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 457 659 950.680951 $47534.0400 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 5 5 4.055556 $202.7800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 286 401 1060.072235 $26501.8400 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 4 4 52.857144 $2642.8600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 519 822 12771.671417 $638583.6400 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 38 49 626.871428 $31343.5800 $50.0000
INTR -T1013 INTERPRETER 2 2 4.500000 $225.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 223 336 4788.688876 $344594.1500 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 7 8 104.857142 $7545.5200 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 243 388 7832.342057 $451142.9200 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 7 7 121.571429 $7002.5100 $57.6000
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 0.344444 $24.7800 $71.9500
OCCT -97530TLHM OT SESSION BY OT ASST 2 2 125.571428 $7232.9200 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 121 194 3171.224597 $228201.3900 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 4 5 85.000000 $6116.6000 $71.9600
PHY -97110HM PT SESSION BY PT ASST 99 165 3130.306347 $180180.4500 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 1 1 17.571429 $1011.4100 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 1 1 24.571429 $1768.1600 $71.9600
PHY -97110TLGTHM PT SESSION BY PT ASST 1 3 15.857143 $912.7300 $57.5600
PHY -97110TLHM PT SESSION BY PT ASST 3 4 41.857143 $2409.2900 $57.5600
SENS -V5050 IN EAR MONAURAL HEARING AID 2 4 5.466666 $1255.1900 $229.6100
SENS -V5060 BEHIND EAR HEARING AID 2 3 5.577778 $1280.7200 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 6 9 9.416667 $4324.3400 $459.2200
SENS -V5264 EARMOLD 10 15 24.577778 $445.6000 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 354 533 8033.284114 $578075.2200 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 9 10 123.571427 $8892.2000 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 18 23 430.285715 $30963.3700 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 3 5 34.314285 $2469.2600 $71.9600
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Subtotal (Total Children Is Unduplicated) 1143 6414 48304.970597 $2846767.5600 $58.9300
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Total 11505 199691.239853 $8210240.1200 $41.1100
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Number of Children (Unduplicated) With at Least One Authorization 2292