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 1438 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 33 34 898.703174 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 10 10 3320.266667 $123513.9200 $37.2000
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Subtotal (Total Children Is Unduplicated) 43 44 4218.969841 $123513.9200 $29.2800
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT COS Exit 4 4 4.000000 $200.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 4 4 8.000000 $647.8400 $80.9800
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 1 1 0.277778 $22.5000 $80.9900
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.000000 $161.9600 $80.9800
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 3 3 6.000000 $485.8800 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 4 4 7.000000 $419.4400 $59.9200
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 37 37 74.000000 $5992.5200 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 14 14 26.266667 $2127.0800 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 11 11 22.000000 $1781.5600 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 7 7 14.000000 $1133.7200 $80.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 11 11 22.000000 $1781.5600 $80.9800
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 2 2 4.000000 $323.9200 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 45 45 90.000000 $5392.8000 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 12 12 24.000000 $1438.0800 $59.9200
OCTF -97168 OT RE-EVAL EST PLAN CARE 18 18 4.644446 $269.9000 $58.1100
OCTF -97168GT OT RE-EVAL EST PLAN CARE 1 1 0.383333 $22.2700 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.061111 $3.5500 $58.1000
OCTH -97167 OT EVAL HIGH COMPLEXITY 19 19 13.696043 $795.8700 $58.1100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 0.177778 $10.3300 $58.1200
PSTF -97164 PT RE-EVAL EST PLAN CARE 7 8 2.554337 $148.4300 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.322222 $18.7200 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 6 6 4.805555 $279.2500 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 7 9 1.883334 $109.4400 $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 39 39 13.928570 $809.3900 $58.1100
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Subtotal (Total Children Is Unduplicated) 178 265 354.156730 $24917.4900 $70.3600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 8 8 8.000000 $40000.0000 $5000.0000
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 160 174 106.440476 $5322.0200 $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 87 92 621.628568 $33567.9700 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 3.571429 $192.8600 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 22 23 174.933333 $14225.5700 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 28 31 176.785717 $11512.2700 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 16 17 97.324604 $7914.4400 $81.3200
PHY -97110HM PT SESSION BY PT ASST 5 6 45.107144 $2937.3700 $65.1200
PHY -97110HMGT PT SESSION BY PT ASST 1 1 20.571429 $1339.6100 $65.1200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 54 58 320.009525 $26023.1700 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 6.000000 $487.9200 $81.3200
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Subtotal (Total Children Is Unduplicated) 340 1129 2104.306348 $161929.3100 $76.9500
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Total 1438 6677.432919 $310360.7300 $46.4800
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Number of Children (Unduplicated) With at Least One Authorization 469