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: 04-01-25 and 06-30-25 Date of Report: 07-19-25 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2762 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 59 59 4326.811111 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 50 50 12809.669841 $476519.7200 $37.2000
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Subtotal (Total Children Is Unduplicated) 109 109 17136.480952 $476519.7200 $27.8100
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.900000 $104.2300 $115.8100
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 3 3 2.230528 $167.3000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 50 50 86.936606 $7040.1300 $80.9800
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 14 14 21.147945 $1712.5700 $80.9800
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 6 6 12.000000 $971.7600 $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 16 16 32.000000 $2591.3600 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 24 24 43.411111 $2601.1900 $59.9200
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 6 7 14.000000 $838.8800 $59.9200
IPDEF -T1024TSTL F/U PSYCH AND DEV EVAL BY EI PROF 1 1 0.317808 $25.7400 $80.9800
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 319 319 633.571428 $51306.6100 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 46 47 94.000000 $7612.1200 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 71 71 142.000000 $11499.1600 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 14 14 26.066667 $2110.8800 $80.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 113 113 224.285714 $18162.6600 $80.9800
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 11 11 22.000000 $1781.5600 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 125 125 250.000000 $14980.0000 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 51 51 100.285714 $6009.1200 $59.9200
OCTF -97168 OT RE-EVAL EST PLAN CARE 49 52 18.694804 $1086.3500 $58.1100
OCTF -97168GT OT RE-EVAL EST PLAN CARE 1 1 0.177778 $10.3300 $58.1200
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 1.150000 $66.8300 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 0.494444 $28.7300 $58.1000
OCTH -97167 OT EVAL HIGH COMPLEXITY 45 46 29.866670 $1735.5700 $58.1100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 5 5 6.000000 $348.6600 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 31 31 8.905554 $517.4900 $58.1100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 2 2 0.494444 $28.7300 $58.1000
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 9 9 7.683334 $446.4800 $58.1100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 12 13 7.205556 $418.7200 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 0.138889 $8.0700 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 80 84 62.377290 $3624.7500 $58.1100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 0.972223 $56.5000 $58.1100
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Subtotal (Total Children Is Unduplicated) 602 1129 1854.314507 $138228.7600 $74.5400
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 11 16 14.090475 $704.5200 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 4 5 4.000000 $200.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 4 4 2.722222 $68.0600 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 178 184 113.532537 $5676.6100 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 5 5 2.133334 $106.6700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 136 140 158.938886 $3973.4700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 78 142 90.433331 $4521.6600 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 1 1 0.611111 $30.5600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 41 81 88.483330 $2212.0800 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 22 40 21.666666 $1083.3300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 11 20 24.616669 $615.4200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 168 172 103.045237 $5152.2500 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 2 2 0.900000 $45.0000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 130 135 148.972218 $3724.3000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 217 223 1570.714305 $84818.5400 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 21 22 129.285716 $6981.4400 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 39 39 263.747626 $21447.9500 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 76 79 701.714296 $45695.6000 $65.1200
OCCT -97530HMGT OT SESSION BY OT ASST 2 2 13.857143 $902.3700 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 17 19 118.857143 $9665.4700 $81.3200
PHY -97110HM PT SESSION BY PT ASST 32 36 266.704764 $17367.8000 $65.1200
SENS -V5060 BEHIND EAR HEARING AID 1 1 1.000000 $229.6100 $229.6100
SENS -V5264 EARMOLD 1 1 0.450000 $8.1600 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 131 138 892.028586 $72539.6900 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 5 5 42.714286 $3473.5400 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 7 7 27.071428 $2201.4500 $81.3200
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 3 5 16.571429 $1347.5900 $81.3200
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Subtotal (Total Children Is Unduplicated) 496 1524 4818.862738 $294793.1100 $61.1700
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Total 2762 23809.658197 $909541.5900 $38.2000
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Number of Children (Unduplicated) With at Least One Authorization 783