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: 07-01-24 and 09-30-24 Date of Report: 04-06-25 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1935 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 55 55 60.404766 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 55 55 60.404766 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 5 5 6.000000 $450.0000 $75.0000
IPDEF -IPDEF_NM F/U PSYCH & DEV EVAL BY NON-MED PRO 1 1 1.000000 $55.5000 $55.5000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 10 10 18.011111 $1458.5400 $80.9800
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 10 10 16.022222 $1297.4800 $80.9800
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 0.011111 $0.9000 $80.9000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 2 2 3.500000 $283.4300 $80.9800
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 12 12 21.011111 $1701.4800 $80.9800
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 3 3 4.500000 $364.4100 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 17 17 26.011111 $1558.5900 $59.9200
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 21 22 32.022222 $1918.7700 $59.9200
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 76 77 150.500000 $12187.4900 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 73 73 142.000000 $11499.1600 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 5 5 10.000000 $809.8000 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 12 12 22.000000 $1781.5600 $80.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 66 66 128.500000 $10405.9300 $80.9800
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 27 27 52.000000 $4210.9600 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 73 73 138.500000 $8298.9200 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 99 101 190.500000 $11414.7600 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $161.9600 $80.9800
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 5 5 10.000000 $809.8000 $80.9800
OCTF -97168 OT RE-EVAL EST PLAN CARE 2 2 0.171004 $9.9400 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 10 10 1.972221 $114.6000 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 3 3 0.561112 $32.6100 $58.1200
OCTH -97167 OT EVAL HIGH COMPLEXITY 7 7 5.288890 $307.3400 $58.1100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 2 2 0.733334 $42.6200 $58.1200
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 1 1 0.344444 $20.0100 $58.1000
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 0.194444 $11.3000 $58.1000
PSTH -97161 PT EVAL LOW COMPLEXITY 14 15 11.983334 $696.3600 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 6 6 4.244445 $246.6500 $58.1100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 0.472222 $27.4400 $58.1100
PSTH -97163TLGT PT EVAL HIGH COMPLEXITY 1 1 0.472222 $27.4400 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 12 12 9.222222 $535.9000 $58.1100
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 2.427778 $141.0800 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 19 21 11.532484 $670.1500 $58.1100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 2.727778 $158.5100 $58.1100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.311111 $18.0800 $58.1100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.744444 $101.3700 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 5 5 5.000000 $290.5500 $58.1100
SPCH -92610GT EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $58.1100 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 2 2 12.285714 $713.9200 $58.1100
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 319 622 1046.778091 $74893.4000 $71.5500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 16 16 16.000000 $80000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 40 45 36.311111 $1815.5600 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 21 23 19.116667 $955.8400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 216 236 252.456344 $12622.7800 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 63 66 72.564282 $3628.2000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 56 60 54.433331 $2721.6600 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 38 39 38.439680 $1921.9800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 86 91 90.131746 $4506.6000 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 36 38 32.953970 $1647.7100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 115 123 118.521426 $5926.0600 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 62 65 57.263488 $2863.1600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 4.433333 $110.8300 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 9 9 23.971429 $647.2300 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 242 259 1411.393674 $76215.2100 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 47 49 237.717464 $12836.7400 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 27 29 152.917464 $12435.2300 $81.3200
OCCT -97530GO OT SESSION BY LICENSED OT 1 1 1.142857 $92.9400 $81.3200
OCCT -97530GT OT SESSION BY LICENSED OT 2 3 12.428571 $1010.7000 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 47 51 309.773808 $25190.7800 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 3 3 12.571428 $1022.3100 $81.3200
PHY -97110TLGT PT SESSION BY LICENSED PT 1 1 12.142857 $987.4600 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 38 41 195.119052 $15867.0600 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 22.142857 $1800.6600 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 3 3 11.714286 $952.6100 $81.3200
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 359 1258 3196.661125 $267804.2700 $83.7800
-------------------------------------------------------------------------------------------------------------------------------------
Total 1935 4303.843982 $342697.6700 $79.6300
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 531