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 1158 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 54 54 60.182544 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 54 54 60.182544 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
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 5 5 8.011111 $648.7400 $80.9800
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 1 1 1.500000 $121.4700 $80.9800
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 4 4 8.000000 $647.8400 $80.9800
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 1 1 2.000000 $161.9600 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 5 5 6.000000 $359.5200 $59.9200
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 7 8 9.511111 $569.9100 $59.9200
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 33 33 63.500000 $5142.2300 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 15 15 28.000000 $2267.4400 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.000000 $161.9600 $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 19 19 36.000000 $2915.2800 $80.9800
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 10 10 18.500000 $1498.1300 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 22 22 40.000000 $2396.8000 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 38 39 72.000000 $4314.2400 $59.9200
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 0.087671 $5.1000 $58.1300
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 0.561111 $32.6100 $58.1100
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 1 1 0.344444 $20.0100 $58.1000
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $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 1 1 0.472222 $27.4400 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 0.286453 $16.6500 $58.1200
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.222222 $12.9100 $58.1000
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 2.000000 $116.2200 $58.1100
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Subtotal (Total Children Is Unduplicated) 97 182 308.940789 $22148.9300 $71.6900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.000000 $15000.0000 $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 4 4 9.142857 $246.8600 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 81 90 467.693655 $25255.4700 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 15 16 74.188890 $4006.2100 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 4 4 26.571429 $2160.7900 $81.3200
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 10.142857 $824.8200 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 9 9 60.700000 $4936.1200 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 2 2 6.785714 $551.8100 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 8.000000 $650.5600 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 2.000000 $162.6400 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 10.714286 $871.2900 $81.3200
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Subtotal (Total Children Is Unduplicated) 290 922 1456.565066 $93411.9000 $64.1300
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Total 1158 1825.688399 $115560.8300 $63.3000
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Number of Children (Unduplicated) With at Least One Authorization 386