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 1509 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 35 35 3472.077777 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 10 10 49.522222 $1842.2300 $37.2000
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Subtotal (Total Children Is Unduplicated) 45 45 3521.599999 $1842.2300 $0.5200
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 3 3 4.087671 $306.5800 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 5 5 10.000000 $809.8000 $80.9800
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 11 11 17.252055 $1033.7500 $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 13 13 26.000000 $2105.4800 $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 20 21 4.566667 $265.3700 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.472222 $27.4400 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 0.522222 $30.3500 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 15 15 11.973821 $695.8000 $58.1100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 0.177778 $10.3300 $58.1200
PSTF -97164 PT RE-EVAL EST PLAN CARE 14 14 4.076559 $236.8900 $58.1100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 2 2 0.522222 $30.3500 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 2.188889 $127.2000 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 4 4 2.533333 $147.2100 $58.1100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 7 7 1.983334 $115.2600 $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 35 38 10.383333 $603.3700 $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) 171 277 362.895662 $25478.6400 $70.2100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.000000 $15000.0000 $5000.0000
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 172 179 97.462690 $4873.0900 $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 148 155 83.380149 $4168.9600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 112 116 126.949999 $3173.7500 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 82 85 621.071434 $33537.8600 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 3 3 7.571429 $408.8600 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 24 25 213.428572 $17356.0200 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 21 26 176.000002 $11461.1100 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 14 15 111.943652 $9103.2500 $81.3200
PHY -97110HM PT SESSION BY PT ASST 8 8 45.000001 $2930.4000 $65.1200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 52 52 362.938099 $29514.0900 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 12.142858 $987.4500 $81.3200
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Subtotal (Total Children Is Unduplicated) 372 1187 2260.150795 $145681.3800 $64.4600
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Total 1509 6144.646456 $173002.2400 $28.1500
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Number of Children (Unduplicated) With at Least One Authorization 467