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: 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 1052 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 32 32 34.188884 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 32 32 34.188884 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 4 4 4.500000 $337.5000 $75.0000
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 10.044444 $601.8600 $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 28 28 56.000000 $4534.8800 $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 4 4 8.000000 $647.8400 $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 1 1 0.194444 $11.3000 $58.1000
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 0.100000 $5.8100 $58.1100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 0.427778 $24.8600 $58.1100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $58.1100 $58.1100
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Subtotal (Total Children Is Unduplicated) 85 165 302.277777 $21420.7000 $70.8600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 3.112329 $15561.5000 $4999.9500
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 36 40 33.711109 $1685.5500 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 18 23 17.172223 $858.6200 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 2.933333 $73.3300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 190 200 256.853962 $12842.6500 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 63 66 75.498413 $3774.9200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 5.071429 $126.7900 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 57 59 63.084921 $3154.2500 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 45 45 53.850791 $2692.5300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 83 87 104.592857 $5229.6400 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 30 32 37.526192 $1876.3200 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.655556 $16.3900 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 114 120 127.067461 $6353.3700 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 76 78 90.162697 $4508.1300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 1.977777 $49.4400 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 4 5 9.933334 $268.2000 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 66 70 353.880958 $19109.5400 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 7 7 49.304763 $2662.4500 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 5 6 36.800001 $2992.5800 $81.3200
OCCT -97530GOGT OT SESSION BY LICENSED OT 1 1 9.714286 $789.9700 $81.3200
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 12.142857 $987.4600 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 2 2 11.500000 $935.1800 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 1 1 7.714286 $627.3300 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 2 9.642857 $784.1600 $81.3200
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Subtotal (Total Children Is Unduplicated) 272 855 1373.904392 $87960.2700 $64.0200
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Total 1052 1710.371053 $109380.9600 $63.9500
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Number of Children (Unduplicated) With at Least One Authorization 339