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: 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 2683 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 49 49 1503.013492 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 51 51 12703.572223 $472572.8900 $37.2000
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Subtotal (Total Children Is Unduplicated) 100 100 14206.585715 $472572.8900 $33.2600
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 9 10 17.000000 $1275.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 38 39 69.888888 $5659.6000 $80.9800
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 4 4 7.000000 $566.8600 $80.9800
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.000000 $80.9800 $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 10 10 20.000000 $1619.6000 $80.9800
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 1 1 2.000000 $161.9600 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 20 20 34.249316 $2052.2200 $59.9200
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 3 3 4.076712 $244.2800 $59.9200
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 298 302 600.000000 $48588.0000 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 42 44 88.000000 $7126.2400 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 38 38 76.000000 $6154.4800 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 17 17 34.000000 $2753.3200 $80.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 95 95 190.000000 $15386.2000 $80.9800
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 8 8 16.000000 $1295.6800 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 154 154 307.000000 $18395.4400 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 16 16 32.000000 $1917.4400 $59.9200
OCTF -97168 OT RE-EVAL EST PLAN CARE 59 67 25.547522 $1484.5800 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 4 4 1.522222 $88.4600 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 5 5 2.450000 $142.3700 $58.1100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 3 3 3.000000 $174.3300 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 38 38 53.011046 $3080.4700 $58.1100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 0.172222 $10.0100 $58.1000
PSTF -97164 PT RE-EVAL EST PLAN CARE 27 28 8.254645 $479.7000 $58.1100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 2 2 0.030214 $1.7600 $58.2700
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.172222 $10.0100 $58.1000
PSTH -97162 PT EVAL MODERATE COMPLEXITY 6 7 2.794445 $162.3900 $58.1100
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 8 8 6.122223 $355.7700 $58.1100
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.522222 $7.8900 $15.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 17 17 13.938890 $810.0000 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 0.105556 $6.1400 $58.1300
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 99 107 35.389197 $2056.4800 $58.1100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 3.205556 $186.2800 $58.1100
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 1.000000 $58.1100 $58.1100
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Subtotal (Total Children Is Unduplicated) 545 1059 1659.453098 $122662.0800 $73.9200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.000000 $15000.0000 $5000.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.522222 $120.9500 $231.6100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 20 22 17.504764 $875.2500 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 2 2 2.000000 $100.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 8 8 6.383333 $159.5800 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 206 210 115.238881 $5761.9100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 146 148 168.684923 $4217.1300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 86 143 78.738890 $3936.9500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 33 56 43.272224 $1081.8100 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 20 35 21.188889 $1059.4500 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 8 14 24.050001 $601.2500 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 177 180 104.161103 $5208.0200 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 2 2 0.777778 $38.8900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 144 148 171.162700 $4279.0700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 237 240 1543.300005 $83338.1900 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 5 5 31.571428 $1704.8500 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 50 51 332.230950 $27017.0300 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 58 61 587.571431 $38262.6400 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 21 24 149.571426 $12163.1600 $81.3200
PHY -97110HM PT SESSION BY PT ASST 33 34 214.665080 $13978.9900 $65.1200
PHY -97110HMGT PT SESSION BY PT ASST 2 2 19.428572 $1265.1900 $65.1200
SENS -V5264 EARMOLD 1 1 0.522222 $9.4700 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 112 117 840.995240 $68389.7100 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 6 6 26.000000 $2114.3200 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 11 11 55.947618 $4549.6500 $81.3200
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Subtotal (Total Children Is Unduplicated) 477 1524 4558.489680 $295233.4500 $64.7700
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Total 2683 20424.528493 $890468.4300 $43.6000
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Number of Children (Unduplicated) With at Least One Authorization 706