Summary Report for FSPSAs Ending During the Report Period Center: 55
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 2531 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 48 50 2198.131748 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 53 54 13838.794444 $632156.1300 $45.6800
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Subtotal (Total Children Is Unduplicated) 101 104 16036.926192 $632156.1300 $39.4200
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT COS Exit 1 2 2.000000 $100.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 6 6 8.419940 $631.5000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 45 47 73.132496 $5922.2600 $80.9800
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 14 14 17.657230 $1429.9000 $80.9800
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 6 6 10.011111 $810.7000 $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 4 4 8.000000 $647.8400 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 12 12 17.364992 $1040.5000 $59.9200
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 7 7 10.153425 $608.3900 $59.9200
IPDEF -T1024TSTL F/U PSYCH AND DEV EVAL BY EI PROF 1 1 2.000000 $161.9600 $80.9800
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 324 331 662.000000 $53608.7600 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 20 20 40.000000 $3239.2000 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 146 147 294.000000 $23808.1200 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 17 17 34.000000 $2753.3200 $80.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 98 98 196.000000 $15872.0800 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 67 68 136.000000 $8149.1200 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 13 13 26.000000 $1557.9200 $59.9200
OCTF -97168 OT RE-EVAL EST PLAN CARE 51 58 12.777777 $742.5100 $58.1100
OCTF -97168GT OT RE-EVAL EST PLAN CARE 2 2 0.277778 $16.1400 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 0.633333 $36.8000 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 39 42 26.944443 $1565.7300 $58.1100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 2 2 3.000000 $174.3300 $58.1100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 26 26 8.049999 $467.7800 $58.1100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 2 2 0.011111 $0.6500 $58.0600
PSTH -97163 PT EVAL HIGH COMPLEXITY 6 6 6.000000 $348.6600 $58.1100
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.411111 $6.2100 $15.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 12 13 25.522221 $1483.0900 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 2 2 0.516667 $30.0300 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 86 90 40.480551 $2352.3300 $58.1100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.183333 $68.7600 $58.1100
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Subtotal (Total Children Is Unduplicated) 610 1044 1666.547518 $127912.7800 $76.7500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.000000 $10000.0000 $5000.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.411111 $95.2200 $231.6100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 11 12 9.827778 $491.3900 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 5 5 5.000000 $250.0000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 171 178 99.542061 $4977.0900 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 4 4 1.366666 $68.3300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 117 124 116.438887 $2910.9700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 60 108 41.994443 $2099.7200 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 1 1 0.277778 $13.8900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 29 58 45.972216 $1149.2900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 25 48 23.188886 $1159.4300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 13 25 23.600001 $590.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 157 165 95.680946 $4784.0200 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 2 2 0.422222 $21.1100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 113 121 115.344444 $2883.6100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 199 209 1322.490466 $71414.5300 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 19 19 101.714285 $5492.5800 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 42 44 232.907938 $18940.0900 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 54 57 356.785714 $23233.8800 $65.1200
OCCT -97530HMGT OT SESSION BY OT ASST 3 3 7.571428 $493.0600 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 14 15 57.714288 $4693.3300 $81.3200
PHY -97110HM PT SESSION BY PT ASST 33 33 236.571427 $15405.5400 $65.1200
SENS -V5264 EARMOLD 1 1 0.411111 $7.4500 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 130 140 575.052376 $46763.2200 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 11.857142 $964.2300 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 3 3 14.138095 $1149.7100 $81.3200
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 3 3 20.428572 $1661.2500 $81.3200
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Subtotal (Total Children Is Unduplicated) 457 1383 3518.710281 $221712.9100 $63.0100
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Total 2531 21222.183991 $981781.8200 $46.2600
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Number of Children (Unduplicated) With at Least One Authorization 887