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: 01-01-25 and 03-31-25 Date of Report: 04-06-25 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2645 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 38 41 2304.203175 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 47 49 12633.972222 $469983.7700 $37.2000
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Subtotal (Total Children Is Unduplicated) 85 90 14938.175397 $469983.7700 $31.4600
Screening, Eval, and Assessment, Class # 02
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 6 7 14.000000 $1050.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 32 32 54.986453 $4452.8000 $80.9800
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 7 7 12.511111 $1013.1500 $80.9800
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 4.000000 $323.9200 $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 9 9 18.000000 $1457.6400 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 21 21 36.246576 $2171.9000 $59.9200
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 4 4 6.093151 $365.1000 $59.9200
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 310 313 620.285714 $50230.7400 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 60 61 122.000000 $9879.5600 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 83 83 164.285714 $13303.8600 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 16 16 31.000000 $2510.3800 $80.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 74 74 148.000000 $11985.0400 $80.9800
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 13 13 26.000000 $2105.4800 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 142 143 285.000000 $17077.2000 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 43 44 88.000000 $5272.9600 $59.9200
OCTF -97168 OT RE-EVAL EST PLAN CARE 55 56 20.899469 $1214.4800 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 5 5 7.165079 $416.3600 $58.1100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 0.079452 $4.6200 $58.1400
OCTH -97166 OT EVAL MODERATE COMPLEXITY 11 11 4.483332 $260.5200 $58.1100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 43 45 36.918265 $2145.3200 $58.1100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 3 3 3.000000 $174.3300 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 30 31 7.528918 $437.5000 $58.1100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 5 5 0.714688 $41.5300 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 6 6 3.405555 $197.8900 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 11 11 6.807154 $395.5600 $58.1100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 0.277778 $16.1400 $58.1100
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.219178 $3.3100 $15.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 15 15 3.472223 $201.7800 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 0.327778 $19.0500 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 95 97 35.927787 $2087.7600 $58.1100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 9.968254 $579.2500 $58.1100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.555556 $90.4000 $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) 638 1128 1781.159185 $132041.8800 $74.1300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 5 5.000000 $25000.0000 $5000.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.888889 $205.8900 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 30 32 23.161113 $1158.0700 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 1 1 0.500000 $25.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 8 8 7.566666 $189.1700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 152 157 79.928584 $3996.4900 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 2 2 1.188889 $59.4500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 112 116 114.311109 $2857.7700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 77 131 60.733342 $3036.7100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 40 75 70.516666 $1762.9200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 26 53 23.922223 $1196.1200 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 1 1 0.855556 $42.7800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 10 19 16.666666 $416.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 131 135 70.819850 $3541.0400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 107 111 115.344444 $2883.6100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 193 202 1122.457140 $60612.7200 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 10 10 84.571429 $4566.8700 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 64 68 366.083334 $29769.8600 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 64 65 427.571428 $27843.4700 $65.1200
OCCT -97530TLHM OT SESSION BY OT ASST 1 1 1.357143 $88.3700 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 39 39 205.138888 $16681.9000 $81.3200
PHY -97110HM PT SESSION BY PT ASST 34 38 268.214285 $17466.1400 $65.1200
PHY -97110HMGT PT SESSION BY PT ASST 1 1 9.142857 $595.3900 $65.1200
SENS -V5264 EARMOLD 1 1 0.888889 $16.1200 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 139 141 781.433330 $63546.1900 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 5 22.857143 $1858.7400 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 9 9 33.704761 $2740.8600 $81.3200
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Subtotal (Total Children Is Unduplicated) 463 1427 3914.824624 $272158.2700 $69.5200
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Total 2645 20634.159206 $874183.9100 $42.3700
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Number of Children (Unduplicated) With at Least One Authorization 904