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: 01-01-25 and 03-31-25 Date of Report: 04-06-25 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1014 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 36 38 18.600000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 36 38 18.600000 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 1.000000 $75.0000 $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 4 4 7.500000 $607.3500 $80.9800
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 4 4 8.000000 $647.8400 $80.9800
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 2 2 2.011111 $162.8600 $80.9800
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 2.000000 $161.9600 $80.9800
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 1 1 1.500000 $121.4700 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 9 9 11.011111 $659.7900 $59.9200
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 4 4 8.000000 $479.3600 $59.9200
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 29 29 58.000000 $4696.8400 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 11 11 21.000000 $1700.5800 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 2 2 4.000000 $323.9200 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 10 10 19.000000 $1538.6200 $80.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 12 12 23.000000 $1862.5400 $80.9800
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 5 5 10.000000 $809.8000 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 30 31 60.000000 $3595.2000 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 33 33 64.000000 $3834.8800 $59.9200
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $161.9600 $80.9800
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 0.422222 $24.5300 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.166667 $9.6900 $58.1200
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 1 1 0.172222 $10.0100 $58.1000
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 0.122222 $7.1000 $58.1000
PSTH -97163TLGT PT EVAL HIGH COMPLEXITY 1 1 0.122222 $7.1000 $58.1000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.344444 $20.0100 $58.1000
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $58.1100 $58.1100
SPCH -92610GT EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.166667 $9.6900 $58.1200
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Subtotal (Total Children Is Unduplicated) 92 170 305.538888 $21641.7000 $70.8300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 4.000000 $20000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 26 27 25.005555 $1250.2800 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 18 20 16.916667 $845.8400 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 194 204 209.114292 $10455.7600 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 62 64 68.519048 $3425.9600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 55 58 55.375401 $2768.7900 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 33 33 33.477780 $1673.9000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 81 83 87.788099 $4389.4300 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 28 28 34.315873 $1715.7900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 116 125 50.469052 $2523.4700 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 64 65 67.669842 $3383.5100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 3.300000 $82.5000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 2.400000 $64.8000 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 67 71 358.912695 $19381.2900 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 11 11 46.336509 $2502.1700 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 4 4 29.285714 $2381.5200 $81.3200
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 0.714286 $58.0900 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 4 4 16.909524 $1375.0900 $81.3200
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Subtotal (Total Children Is Unduplicated) 266 806 1110.510337 $78278.1700 $70.4900
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Total 1014 1434.649225 $99919.8700 $69.6500
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Number of Children (Unduplicated) With at Least One Authorization 366