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 1418 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 36 36 1815.366666 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 15 15 2506.888890 $93256.2700 $37.2000
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Subtotal (Total Children Is Unduplicated) 51 51 4322.255556 $93256.2700 $21.5800
Screening, Eval, and Assessment, Class # 02
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 7 7 12.175342 $985.9600 $80.9800
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 1 1 2.000000 $161.9600 $80.9800
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.000000 $161.9600 $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 2 2 4.000000 $323.9200 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 8 8 14.060274 $842.4900 $59.9200
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 52 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 15 15 30.000000 $2429.4000 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 7 7 14.000000 $1133.7200 $80.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 21 21 42.000000 $3401.1600 $80.9800
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 4 4 8.000000 $647.8400 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 55 55 110.000000 $6591.2000 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 19 19 38.000000 $2276.9600 $59.9200
OCTF -97168 OT RE-EVAL EST PLAN CARE 19 21 25.460320 $1479.5100 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 3 3 6.142857 $356.9600 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 3 3 1.844444 $107.1800 $58.1100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 13 13 13.088889 $760.6000 $58.1100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 14 14 5.138891 $298.6300 $58.1100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 2 2 0.244445 $14.2100 $58.1200
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 3 3 2.111111 $122.6800 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 8 9 31.866667 $1851.7700 $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 33 34 12.815078 $744.6800 $58.1100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 5.825397 $338.5100 $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) 197 316 516.834826 $35956.6500 $69.5700
EI Services, Class # 03
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 65 67 480.571432 $25950.8700 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 5 5 38.000001 $2052.0000 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 17 18 86.571430 $7039.9700 $81.3200
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 15.714286 $1277.8900 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 20 20 166.285716 $10828.5200 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 12 12 108.571431 $8829.0200 $81.3200
PHY -97110HM PT SESSION BY PT ASST 11 12 68.714286 $4474.6800 $65.1200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 41 43 282.142861 $22943.8400 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 5 6 23.142859 $1881.9700 $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) 336 1051 1922.114305 $109119.5000 $56.7700
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Total 1418 6761.204687 $238332.4200 $35.2500
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Number of Children (Unduplicated) With at Least One Authorization 443