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 1427 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 55 55 3829.611111 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 9 9 1881.522222 $69992.6300 $37.2000
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Subtotal (Total Children Is Unduplicated) 64 64 5711.133333 $69992.6300 $12.2600
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 2 2 0.230528 $17.3000 $75.0200
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 9 9 18.000000 $1457.6400 $80.9800
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 5 5 8.000000 $647.8400 $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 10 10 19.000000 $1138.4800 $59.9200
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 2 2 4.000000 $239.6800 $59.9200
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 55 55 110.000000 $8907.8000 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 7 7 14.000000 $1133.7200 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 18 18 36.000000 $2915.2800 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 3 3 6.000000 $485.8800 $80.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 28 28 56.000000 $4534.8800 $80.9800
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 5 5 10.000000 $809.8000 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 42 42 84.000000 $5033.2800 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 17 17 32.285714 $1934.5600 $59.9200
OCTF -97168 OT RE-EVAL EST PLAN CARE 11 11 4.619407 $268.4300 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 9 9 7.316667 $425.1700 $58.1100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 7 7 0.788889 $45.8400 $58.1100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 0.172222 $10.0100 $58.1000
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 1.038889 $60.3700 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 3 4 3.405556 $197.9000 $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 16 16 5.088888 $295.7100 $58.1100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.027778 $1.6200 $58.1600
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Subtotal (Total Children Is Unduplicated) 171 262 431.013427 $31437.5500 $72.9400
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 172 177 109.799203 $5489.9400 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 5 5 2.133334 $106.6700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 135 139 158.661108 $3966.5200 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 76 140 89.866664 $4493.3200 $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 165 169 101.767458 $5088.3600 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 2 2 0.900000 $45.0000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 129 134 148.694440 $3717.3500 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 72 75 584.571434 $31566.8500 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 6 7 38.857143 $2098.2900 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 9 9 65.285716 $5309.0400 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 20 20 155.428574 $10121.5000 $65.1200
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 9.285714 $604.6800 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 8 8 41.857144 $3403.8200 $81.3200
PHY -97110HM PT SESSION BY PT ASST 6 8 39.000000 $2539.6900 $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 36 36 238.119051 $19363.8000 $81.3200
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 2 2 5.142857 $418.2200 $81.3200
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Subtotal (Total Children Is Unduplicated) 347 1101 1947.010313 $103484.7700 $53.1500
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Total 1427 8089.157073 $204914.9400 $25.3300
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Number of Children (Unduplicated) With at Least One Authorization 481