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 1307 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 46 48 2197.042859 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 11 11 2993.344444 $136735.9700 $45.6800
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Subtotal (Total Children Is Unduplicated) 57 59 5190.387303 $136735.9700 $26.3400
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT COS Exit 1 2 2.000000 $100.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 8 9 18.000000 $1457.6400 $80.9800
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 3 3 4.169863 $337.6800 $80.9800
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 4.000000 $323.9200 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 4 4 8.000000 $479.3600 $59.9200
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 1 1 1.000000 $59.9200 $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 64 66 132.000000 $10689.3600 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 2 2 4.000000 $323.9200 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 26 27 54.000000 $4372.9200 $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 24 24 48.000000 $3887.0400 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 25 25 50.000000 $2996.0000 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 6 6 12.000000 $719.0400 $59.9200
OCTF -97168 OT RE-EVAL EST PLAN CARE 14 15 3.216667 $186.9200 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 7 9 8.338889 $484.5700 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 8 8 2.188888 $127.1900 $58.1100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 0.177778 $10.3300 $58.1200
PSTH -97163 PT EVAL HIGH COMPLEXITY 3 3 3.000000 $174.3300 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 4 5 3.266667 $189.8300 $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 27 28 8.789683 $510.7800 $58.1100
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Subtotal (Total Children Is Unduplicated) 156 246 374.665102 $28108.6200 $75.0200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.000000 $10000.0000 $5000.0000
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 166 172 96.730949 $4836.5300 $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 59 107 41.416665 $2070.8300 $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 154 162 93.603168 $4680.1300 $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 72 72 464.357140 $25075.3000 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 4 4 16.285714 $879.4300 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 13 13 51.285714 $4170.5600 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 16 16 89.142858 $5804.9800 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 6 6 23.285716 $1893.5900 $81.3200
PHY -97110HM PT SESSION BY PT ASST 7 7 60.857143 $3963.0100 $65.1200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 36 39 213.714285 $17379.2300 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 0.428571 $34.8500 $81.3300
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 6.000000 $487.9200 $81.3200
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Subtotal (Total Children Is Unduplicated) 317 1002 1500.546801 $90814.3800 $60.5200
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Total 1307 7065.599206 $255658.9700 $36.1800
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Number of Children (Unduplicated) With at Least One Authorization 457