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: 10-01-24 and 12-31-24 Date of Report: 03-31-25 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1498 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 38 2956.600000 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 8 8 2952.000000 $109814.4000 $37.2000
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Subtotal (Total Children Is Unduplicated) 45 46 5908.600000 $109814.4000 $18.5900
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT COS Exit 1 1 1.000000 $50.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 2 2.082192 $156.1700 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 8 8 16.000000 $1295.6800 $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 4 4 8.000000 $647.8400 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 10 12 18.941400 $1134.9700 $59.9200
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 1 1 0.377778 $22.6400 $59.9200
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 51 53 106.000000 $8583.8800 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 12 12 24.000000 $1943.5200 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 6 6 12.000000 $971.7600 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 8 8 16.000000 $1295.6800 $80.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 22 22 44.000000 $3563.1200 $80.9800
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 1 1 2.000000 $161.9600 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 55 55 109.000000 $6531.2800 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 5 5 10.000000 $599.2000 $59.9200
OCTF -97168 OT RE-EVAL EST PLAN CARE 13 13 4.633333 $269.2400 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.383333 $22.2700 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 13 13 14.305556 $831.3000 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 8 8 1.335161 $77.5900 $58.1200
PSTH -97163 PT EVAL HIGH COMPLEXITY 3 3 4.000000 $232.4400 $58.1100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 7 7 0.755556 $43.9100 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 38 39 12.072223 $701.5200 $58.1100
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Subtotal (Total Children Is Unduplicated) 186 277 410.886532 $29414.1500 $71.5900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 1.788888 $8944.0000 $4999.7500
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 20 22 17.993652 $899.6900 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 2 2 2.000000 $100.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 7 7 4.083333 $102.0800 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 197 204 106.516666 $5325.8300 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 1 1 0.411111 $20.5600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 122 126 133.361109 $3334.0200 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 91 156 78.465077 $3923.2500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 33 63 69.461111 $1736.5300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 28 55 29.244445 $1462.2300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 14 28 40.522223 $1013.0600 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 172 179 96.805553 $4840.2700 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 1 2 0.055556 $2.7800 $50.0400
CONSP -CONSP CONSULT, SLP, PHONE 119 126 129.972222 $3249.3100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 96 100 647.676192 $34974.5300 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 22 24 148.000001 $12035.3400 $81.3200
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 2.285714 $185.8700 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 10 12 64.428570 $4195.6000 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 11 11 81.714285 $6645.0200 $81.3200
PHY -97110HM PT SESSION BY PT ASST 8 8 54.035715 $3518.8000 $65.1200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 39 42 240.000001 $19516.7900 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 9.142857 $743.4900 $81.3200
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Subtotal (Total Children Is Unduplicated) 351 1175 1957.964281 $116769.0300 $59.6400
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Total 1498 8277.450813 $255997.5800 $30.9300
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Number of Children (Unduplicated) With at Least One Authorization 508