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 1236 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 43 43 2209.320634 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 9 9 2665.633333 $121766.1300 $45.6800
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Subtotal (Total Children Is Unduplicated) 52 52 4874.953967 $121766.1300 $24.9800
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 -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 7 7 12.005556 $719.3800 $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 12 13 2.977093 $173.0000 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 7 10 7.838889 $455.5200 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 8 9 1.242847 $72.2300 $58.1200
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 0.177778 $10.3300 $58.1200
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.483333 $28.0800 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 1.388889 $80.7100 $58.1100
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.377778 $5.7100 $15.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 3 3 1.327778 $77.1600 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 24 25 7.077887 $411.3000 $58.1100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $58.1100 $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) 146 246 374.489913 $28074.8500 $74.9700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $231.6200 $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 159 163 103.134124 $5156.7000 $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 137 140 90.573010 $4528.6300 $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 71 71 418.428565 $22595.1800 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 6 6 64.714286 $3494.5800 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 12 12 90.714285 $7376.9000 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 10 10 62.999999 $4102.5600 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 7 7 39.428570 $3206.3400 $81.3200
PHY -97110HM PT SESSION BY PT ASST 5 5 44.428572 $2893.1800 $65.1200
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 1.000000 $459.2200 $459.2200
SENS -V5264 EARMOLD 1 1 0.377778 $6.8500 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 36 37 251.533329 $20454.6900 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 20.285714 $1649.6300 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 6.571429 $534.3900 $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) 307 938 1649.273793 $96460.6900 $58.4900
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Total 1236 6898.717673 $246301.6800 $35.7000
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Number of Children (Unduplicated) With at Least One Authorization 402