Summary Report for FSPSAs Ending During the Report Period Center: 05
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: 10-01-25 and 12-31-25 Date of Report: 01-07-26 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2034 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 29 30 24.485715 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 1.011111 $46.1900 $45.6800
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Subtotal (Total Children Is Unduplicated) 30 31 25.496826 $46.1900 $1.8100
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT COS Exit 6 7 6.500000 $325.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 8 9 11.522222 $864.1700 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 5 5 6.022222 $487.6800 $80.9800
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 6 6 10.011111 $810.7000 $80.9800
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 3 3 5.000000 $404.9000 $80.9800
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 3 3 6.000000 $485.8800 $80.9800
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 4 4 4.022222 $325.7200 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 20 21 36.000000 $2157.1200 $59.9200
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 13 13 16.044444 $961.3800 $59.9200
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 116 116 228.000000 $18463.4400 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 62 63 126.000000 $10203.4800 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 2 2 4.000000 $323.9200 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 26 26 51.500000 $4170.4700 $80.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 62 63 123.500000 $10001.0300 $80.9800
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 20 20 39.000000 $3158.2200 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 80 82 163.000000 $9766.9600 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 138 138 275.000000 $16478.0000 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 3 3 6.000000 $485.8800 $80.9800
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $161.9600 $80.9800
OCTF -97168GT OT RE-EVAL EST PLAN CARE 1 1 0.027778 $1.6200 $58.1600
OCTH -97165 OT EVAL LOW COMPLEXITY 9 9 3.005554 $174.6400 $58.1100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 0.005556 $0.3300 $58.5700
OCTH -97167 OT EVAL HIGH COMPLEXITY 3 3 2.588888 $150.4400 $58.1100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 0.422222 $24.5300 $58.1100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 2 2 0.483333 $28.0800 $58.1100
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 1 1 0.327778 $19.0500 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 1.000000 $58.1100 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 14 14 13.597620 $790.1600 $58.1100
PSTH -97161GT PT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 1 1 0.138889 $8.0700 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 12 13 6.083333 $353.5000 $58.1100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 2 2 1.372222 $79.7400 $58.1100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 6 6 3.972222 $230.8200 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 10 10 7.450000 $432.9200 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 0.294444 $17.1100 $58.1000
SPCH -92521TL EVAL OF SPEECH FLUENCY 1 1 0.244444 $14.2000 $58.1000
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.394444 $22.9200 $58.1000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 19 20 10.066666 $584.9700 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 2.427778 $141.0800 $58.1100
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 3 2.666666 $154.9600 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 5 5 22.542857 $1309.9600 $58.1100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 1 1.433333 $83.2900 $58.1100
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Subtotal (Total Children Is Unduplicated) 376 686 1200.668248 $84774.5100 $70.6100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 23 25 19.838051 $99190.5000 $5000.0100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 66 71 84.765077 $4238.2400 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 28 37 32.455555 $1622.7800 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 197 206 243.825406 $12191.3200 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 64 72 69.297623 $3464.9000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 50 54 46.766668 $2338.3400 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 51 54 52.555560 $2627.8000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 88 92 84.183335 $4209.1800 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 54 54 57.219846 $2861.0200 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.900000 $47.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 90 91 95.056350 $4752.8300 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 76 80 71.700003 $3585.0200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 3.377779 $84.4500 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 16 17 27.947620 $754.5900 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 266 290 1484.411901 $80158.2600 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 36 37 211.190476 $11404.3000 $54.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3 3 10.142857 $121.7100 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 23 28 157.428570 $12802.1100 $81.3200
OCCT -97530GO OT SESSION BY LICENSED OT 2 2 11.571429 $940.9900 $81.3200
OCCT -97530GOGT OT SESSION BY LICENSED OT 1 1 3.714286 $302.0500 $81.3200
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 2.142857 $174.2600 $81.3200
OCCT -97530TL OT SESSION BY LICENSED OT 2 2 8.000000 $650.5600 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 47 47 272.138097 $22130.2800 $81.3200
PHY -97110GP PT SESSION BY LICENSED PT 6 7 26.076192 $2120.5200 $81.3200
PHY -97110GPGT PT SESSION BY LICENSED PT 1 1 0.966667 $78.6100 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 1 1 1.571429 $127.7900 $81.3200
PHY -97110TLGP PT SESSION BY LICENSED PT 1 1 7.571429 $615.7100 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 31 33 182.604761 $14849.4200 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 4.142857 $336.9000 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 2 2 8.000000 $650.5600 $81.3200
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 4.857143 $394.9800 $81.3200
TRAV -TRAVS Travel by mile 1 1 1.000000 $0.4500 $0.4500
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Subtotal (Total Children Is Unduplicated) 365 1317 3288.419824 $289827.8900 $88.1400
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Total 2034 4514.584898 $374648.5800 $82.9900
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Number of Children (Unduplicated) With at Least One Authorization 663