Summary Report for FSPSAs Ending During the Report Period Center: 05
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: 10-01-23 and 12-31-23 Date of Report: 01-14-24 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1114 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 21 21 30.787300 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 21 21 30.787300 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 3 4 6.109589 $458.2200 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 6.000000 $450.0000 $75.0000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TLTSGT F/U PHYC AND DEV EVAL BY EI PROF 1 1 0.005556 $0.4200 $75.5900
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 5 5 6.344444 $352.1100 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 4 4 8.000000 $444.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 23 24 47.000000 $3525.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 13 13 23.500000 $1762.5000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 3 3 5.500000 $412.5000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 9 9 17.000000 $1275.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 15 15 29.000000 $2175.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 8 8 15.500000 $1162.5000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 21 21 41.000000 $2275.5000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 22 23 45.000000 $2497.5000 $55.5000
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 0.711111 $36.5600 $51.4100
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Subtotal (Total Children Is Unduplicated) 75 139 257.670700 $17328.2200 $67.2500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 35 40 38.161111 $1908.0600 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 17 21 20.850000 $1042.5000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 238 250 309.757931 $15487.8700 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 65 68 85.915079 $4295.7400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 100 105 101.950001 $5097.5100 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 69 72 85.446822 $4272.3200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 71 73 65.713889 $3285.7000 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 30 30 27.280555 $1364.0300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 116 120 148.393249 $7419.6300 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 62 65 71.705950 $3585.2700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.377778 $9.4500 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 3.133334 $78.3400 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 6 6 27.071429 $1353.5700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 68 74 430.811114 $21540.5500 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 16 18 85.806351 $4290.3100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 3 3 14.495239 $1043.0800 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 1 1 0.928571 $66.8200 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 2 5.000000 $359.8000 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 6.142857 $442.0400 $71.9600
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Subtotal (Total Children Is Unduplicated) 312 954 1530.941260 $81967.5400 $53.5400
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Total 1114 1819.399260 $99295.7600 $54.5800
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Number of Children (Unduplicated) With at Least One Authorization 392