Summary Report for FSPSAs Initiated During the Report Period Center: 55
This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start 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 starting 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 2802 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 37 37 3473.766666 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 46 46 10162.869048 $378058.7300 $37.2000
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Subtotal (Total Children Is Unduplicated) 83 83 13636.635714 $378058.7300 $27.7200
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 11 15 24.243226 $1818.2400 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 45 45 77.422068 $6269.6300 $80.9800
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 5 5 6.637290 $537.4900 $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 24 24 41.279452 $2473.4700 $59.9200
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 3 3 2.180821 $130.6700 $59.9200
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 269 272 541.066667 $43815.5800 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 48 51 102.000000 $8259.9600 $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 61 63 15.499999 $900.7000 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.472222 $27.4400 $58.1100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 7 7 2.577778 $149.8000 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 41 41 30.673819 $1782.4400 $58.1100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 4 4 2.277778 $132.3600 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 28 28 8.063088 $468.5400 $58.1100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 3 3 0.700000 $40.6800 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.138889 $8.0700 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 5 6 4.605556 $267.6300 $58.1100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 2 2 1.466667 $85.2300 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 18 18 14.113089 $820.1100 $58.1100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 0.122222 $7.1000 $58.1000
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.010959 $0.1700 $15.1700
SPCH -92521 EVAL OF SPEECH FLUENCY 20 20 5.788891 $336.4000 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 3 3 2.338889 $135.9100 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 100 111 29.880599 $1736.3900 $58.1100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 5.194444 $301.8500 $58.1100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 -0.127777 $-7.4200 $58.0700
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 1.000000 $58.1100 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $58.1100 $58.1100
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Subtotal (Total Children Is Unduplicated) 576 1085 1612.704414 $119286.9400 $73.9700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.000000 $15000.0000 $5000.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.044444 $10.2800 $231.3900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 22 27 13.620638 $681.0500 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 2 2 1.500000 $75.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 12 12 7.133333 $178.3300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 173 180 98.140468 $4906.9800 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 2 2 1.088888 $54.4400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 121 125 135.455557 $3386.3900 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 97 164 77.716670 $3885.8500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 50 93 95.207936 $2380.2000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 33 65 33.327775 $1666.3800 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 1 1 0.144444 $7.2200 $49.9800
CONPP -CONPP CONSULT, PT, PHONE 14 26 34.066669 $851.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 149 156 84.057927 $4202.8500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 112 116 126.949999 $3173.7500 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 208 216 1552.785738 $83850.4200 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 10 10 62.857143 $3394.2900 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 74 79 476.004767 $38708.7200 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 81 92 653.000006 $42523.3300 $65.1200
OCCT -97530TLHM OT SESSION BY OT ASST 1 1 5.285714 $344.2000 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 42 43 273.357940 $22229.4500 $81.3200
PHY -97110HM PT SESSION BY PT ASST 41 43 258.714289 $16847.4800 $65.1200
SENS -V5264 EARMOLD 1 1 0.044444 $0.8100 $18.1100
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 153 156 872.580971 $70958.1400 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 7 9 26.714288 $2172.3900 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 11 11 48.723812 $3962.2100 $81.3200
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Subtotal (Total Children Is Unduplicated) 527 1634 4941.523860 $325451.8300 $65.8600
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Total 2802 20190.863988 $822797.5100 $40.7500
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Number of Children (Unduplicated) With at Least One Authorization 754