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: 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 2359 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 46 2208.587300 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 40 40 10829.300001 $494682.4300 $45.6800
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Subtotal (Total Children Is Unduplicated) 86 86 13037.887301 $494682.4300 $37.9400
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.3200 $45.3200
EXIT -EXIT COS Exit 1 2 2.000000 $100.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 5 5 6.325495 $474.4100 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 40 41 67.958447 $5503.2600 $80.9800
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 13 13 19.087367 $1545.7100 $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 13 13 21.155556 $1267.6400 $59.9200
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 7 7 9.120548 $546.5000 $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 43 49 14.060426 $817.0500 $58.1100
OCTF -97168GT OT RE-EVAL EST PLAN CARE 1 1 0.250000 $14.5300 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.227778 $13.2400 $58.1200
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 31 34 23.365827 $1357.7800 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 16 17 3.698403 $214.9300 $58.1100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 2 2 0.011111 $0.6500 $58.0600
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.483333 $28.0800 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 6 6 4.483333 $260.5200 $58.1100
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 2 2 0.988889 $14.9400 $15.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 9 9 3.438889 $199.8300 $58.1100
SPCH -92521TL EVAL OF SPEECH FLUENCY 1 1 0.466667 $27.1200 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 80 83 29.667965 $1724.0300 $58.1100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 6 6 3.355555 $194.9900 $58.1100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.422222 $24.5300 $58.1100
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Subtotal (Total Children Is Unduplicated) 556 1002 1622.578922 $125204.1500 $77.1600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 1.611111 $373.1600 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 11 12 9.127778 $456.3900 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 5 5 5.000000 $250.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 1.211111 $30.2800 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 160 164 103.578568 $5178.9200 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 3 3 1.888889 $94.4500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 108 112 116.302382 $2907.5600 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 69 120 88.827781 $4441.4100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 35 64 71.616667 $1790.4200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 17 33 14.688887 $734.4400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 12 24 21.766668 $544.1700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 138 141 91.017454 $4550.8500 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 3 3 2.100000 $105.0000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 98 101 113.411112 $2835.2800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 196 201 1382.142846 $74635.7800 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 15 16 129.857143 $7012.2900 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 38 38 280.649999 $22822.4700 $81.3200
OCCT -97530GO OT SESSION BY LICENSED OT 1 1 7.000000 $569.2400 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 51 52 475.749998 $30980.8300 $65.1200
OCCT -97530HMGT OT SESSION BY OT ASST 4 4 37.142857 $2418.7500 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 17 17 142.714283 $11605.5400 $81.3200
PHY -97110HM PT SESSION BY PT ASST 20 21 170.000001 $11070.3800 $65.1200
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 1.000000 $459.2200 $459.2200
SENS -V5264 EARMOLD 2 2 0.988889 $17.9300 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 120 125 923.309513 $75083.5400 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 28.428571 $2311.8100 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 2 2 8.904762 $724.1300 $81.3200
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 7.142857 $580.8600 $81.3200
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Subtotal (Total Children Is Unduplicated) 447 1271 4238.180127 $269585.0600 $63.6100
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Total 2359 18898.646350 $889471.6400 $47.0700
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Number of Children (Unduplicated) With at Least One Authorization 721