Summary Report for FSPSAs Initiated During the Report Period Center: 05
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: 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 1997 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 29 4.666666 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 4 4 -0.677778 $-30.9600 $45.6800
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Subtotal (Total Children Is Unduplicated) 33 33 3.988888 $-30.9600 $-7.7600
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT COS Exit 3 3 3.000000 $150.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 7 8 10.022222 $751.6700 $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 2 2 4.000000 $323.9200 $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 3.022222 $244.7400 $80.9800
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 1 1 1.000000 $80.9800 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 17 18 30.000000 $1797.6000 $59.9200
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 14 14 17.044444 $1021.3000 $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 61 62 124.000000 $10041.5200 $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 27 27 53.500000 $4332.4300 $80.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 60 61 119.500000 $9677.1100 $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 83 85 170.714285 $10229.2000 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 137 137 273.000000 $16358.1600 $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 -97168 OT RE-EVAL EST PLAN CARE 1 1 0.094444 $5.4900 $58.0800
OCTH -97165 OT EVAL LOW COMPLEXITY 8 8 5.305556 $308.3100 $58.1100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 0.005556 $0.3300 $58.5700
OCTH -97167 OT EVAL HIGH COMPLEXITY 7 8 2.017276 $117.2300 $58.1100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 2 2 0.533333 $30.9900 $58.1100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 2 2 0.583333 $33.9000 $58.1100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 0.316667 $18.4000 $58.1200
PSTH -97161 PT EVAL LOW COMPLEXITY 13 13 9.405555 $546.5500 $58.1100
PSTH -97161GT PT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 8 8 3.744445 $217.5900 $58.1100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 0.283333 $16.4600 $58.1000
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 15 15 10.695129 $621.4900 $58.1100
SPCH -92521TL EVAL OF SPEECH FLUENCY 2 2 3.266667 $189.8300 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 9 9 6.905555 $401.2800 $58.1100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.305556 $17.7600 $58.1200
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $58.1100 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 8 8 6.805555 $395.4700 $58.1100
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $58.1100 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 6 6 31.861906 $1851.4900 $58.1100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 1 1.466667 $85.2300 $58.1100
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Subtotal (Total Children Is Unduplicated) 331 669 1197.433039 $84476.5300 $70.5500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 29 32 28.697489 $143488.0000 $5000.0200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 50 55 51.455554 $2572.7700 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 27 36 30.144444 $1507.2200 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 0.100000 $2.5000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 212 217 251.769834 $12588.4700 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 68 71 83.794444 $4189.7200 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 56 56 57.725392 $2886.2500 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 52 54 68.057140 $3402.8500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 86 88 89.025394 $4451.2600 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 50 50 64.955557 $3247.7900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 4 4 0.366667 $9.1700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 115 117 96.724596 $4836.2000 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 76 78 97.439683 $4872.0000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 6 7 8.355555 $208.8900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 13 13 38.623808 $1042.8500 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 264 273 1607.761885 $86819.1700 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 34 35 211.114281 $11400.1900 $54.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1 1 1.000000 $12.0000 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 18 20 151.714286 $12337.4100 $81.3200
OCCT -97530GO OT SESSION BY LICENSED OT 1 1 2.857143 $232.3400 $81.3200
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 10.000000 $813.2000 $81.3200
OCCT -97530TL OT SESSION BY LICENSED OT 2 2 18.428571 $1498.6100 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 43 44 220.188887 $17905.7800 $81.3200
PHY -97110GP PT SESSION BY LICENSED PT 6 6 48.428572 $3938.2100 $81.3200
PHY -97110GPGT PT SESSION BY LICENSED PT 2 2 13.428571 $1092.0100 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 26 28 173.561899 $14114.0600 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 7.061904 $574.2700 $81.3200
TRAV -TRAVS Travel by mile 1 1 1.000000 $0.4500 $0.4500
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Subtotal (Total Children Is Unduplicated) 361 1295 3433.781556 $340043.6100 $99.0300
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Total 1997 4635.203483 $424489.1800 $91.5800
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Number of Children (Unduplicated) With at Least One Authorization 522