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: 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 2623 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 38 1815.922221 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 61 61 13493.033334 $501940.8400 $37.2000
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Subtotal (Total Children Is Unduplicated) 98 99 15308.955555 $501940.8400 $32.7900
Screening, Eval, and Assessment, Class # 02
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 4 5 10.000000 $750.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 35 35 65.342009 $5291.4000 $80.9800
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 6 6 12.000000 $971.7600 $80.9800
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 4 4 6.000000 $485.8800 $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 20 20 34.279452 $2054.0300 $59.9200
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 3 3 6.000000 $359.5200 $59.9200
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 309 312 620.285714 $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 75 75 150.000000 $12147.0000 $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 44 46 34.182543 $1986.3600 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 4 4 7.142857 $415.0700 $58.1100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 0.079452 $4.6200 $58.1400
OCTH -97166 OT EVAL MODERATE COMPLEXITY 7 7 4.411111 $256.3300 $58.1100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 48 50 45.368266 $2636.3500 $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 30 10.629149 $617.6700 $58.1100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 3 3 0.323897 $18.8300 $58.1300
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 2.161111 $125.5800 $58.1100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 13 13 7.513165 $436.5800 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 13 14 33.422222 $1942.1600 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 0.061111 $3.5500 $58.1000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 81 86 42.744813 $2483.9000 $58.1100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 5.825397 $338.5100 $58.1100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $58.1100 $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) 575 1100 1844.057983 $135951.7200 $73.7200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.000000 $15000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 31 33 23.177779 $1158.9000 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 1 1 0.500000 $25.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 7 7 7.000000 $175.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 161 167 89.238891 $4461.9600 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 2 2 1.877778 $93.8900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 114 116 119.355563 $2983.9100 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 91 145 87.033320 $4351.6000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 53 90 92.283331 $2307.0800 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 25 48 24.733335 $1236.6800 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 1 1 0.222222 $11.1100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 11 22 22.866666 $571.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 124 127 66.811110 $3340.5500 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 1 1 0.877778 $43.8900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 104 106 113.422230 $2835.5800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 185 193 1287.714304 $69536.5500 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 18 18 101.285716 $5469.4300 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 58 62 360.185719 $29290.2900 $81.3200
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 23.571429 $1916.8300 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 65 65 487.178574 $31725.0800 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 39 41 276.142862 $22455.9200 $81.3200
PHY -97110HM PT SESSION BY PT ASST 38 39 289.928573 $18880.1600 $65.1200
PHY -97110HMGT PT SESSION BY PT ASST 1 1 3.714286 $241.8800 $65.1200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 120 124 841.233340 $68409.1200 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 5 6 23.142859 $1881.9700 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 3 3 21.214286 $1725.1400 $81.3200
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 3.000000 $243.9600 $81.3200
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Subtotal (Total Children Is Unduplicated) 472 1424 4370.711951 $290373.1100 $66.4400
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Total 2623 21523.725489 $928265.6700 $43.1300
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Number of Children (Unduplicated) With at Least One Authorization 748