Summary Report for FSPSAs Initiated During the Report Period Center: 05
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: 10-01-23 and 12-31-23 Date of Report: 01-14-24 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 978 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 18 18 26.512699 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 18 18 26.512699 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 3 6.000000 $450.0000 $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 4 4 6.000000 $333.0000 $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 8 8 15.000000 $1125.0000 $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 22 22 43.000000 $2386.5000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 22 23 45.000000 $2497.5000 $55.5000
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.388889 $19.9900 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.266667 $13.7100 $51.4200
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 2.000000 $102.8200 $51.4100
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Subtotal (Total Children Is Unduplicated) 73 138 258.161112 $17310.4400 $67.0500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 81.000000 $405000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 35 40 36.816666 $1840.8300 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 16 19 19.750000 $987.5000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 199 206 272.317351 $13615.8700 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 57 57 74.239683 $3711.9800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 75 80 78.470236 $3923.5000 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 48 50 60.755555 $3037.7800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.142857 $53.5700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 69 72 83.425399 $4171.2800 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 30 30 29.611907 $1480.6000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 115 121 149.103174 $7455.1500 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 52 53 69.011905 $3450.5900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 5 6.388888 $159.7200 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 0.700000 $17.5000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 3 22.428571 $1121.4300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 61 65 298.004769 $14900.2200 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 8 8 38.085716 $1904.2800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 5.285715 $380.3600 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 4 4 16.814285 $1209.9600 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 2 24.285715 $1747.6000 $71.9600
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Subtotal (Total Children Is Unduplicated) 257 822 1369.638392 $470194.7200 $343.3000
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Total 978 1654.312203 $487505.1600 $294.6900
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Number of Children (Unduplicated) With at Least One Authorization 310