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 1440 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 47 47 1490.713492 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 5 5 1728.988889 $64318.3900 $37.2000
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Subtotal (Total Children Is Unduplicated) 52 52 3219.702381 $64318.3900 $19.9800
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 4.000000 $300.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 9 10 20.000000 $1619.6000 $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 5 5 10.000000 $599.2000 $59.9200
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 53 55 108.000000 $8745.8400 $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 17 18 4.927778 $286.3500 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 7 7 4.938889 $287.0000 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 6 7 2.000001 $116.2300 $58.1100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 0.024658 $1.4400 $58.2100
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 1.238889 $71.9900 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 6 6 1.516668 $88.1400 $58.1200
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 23 25 8.022224 $466.1800 $58.1100
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Subtotal (Total Children Is Unduplicated) 157 254 393.669107 $28566.4000 $72.5600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.000000 $10000.0000 $5000.0000
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 144 147 168.896033 $4222.4000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 86 88 535.385716 $28910.8200 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 2 2 9.142857 $493.7100 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 17 17 110.285713 $8968.4300 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 9 11 101.571429 $6614.3200 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 9 10 45.571428 $3705.8700 $81.3200
PHY -97110HM PT SESSION BY PT ASST 3 3 23.000000 $1497.7600 $65.1200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 28 29 213.857142 $17390.8700 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 4 4 18.285714 $1486.9900 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 11.000000 $894.5200 $81.3200
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Subtotal (Total Children Is Unduplicated) 346 1134 1820.996818 $107225.9200 $58.8800
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Total 1440 5434.368306 $200110.7100 $36.8200
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Number of Children (Unduplicated) With at Least One Authorization 447