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: 04-01-25 and 06-30-25 Date of Report: 07-19-25 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1020 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 40 42 40.450795 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 40 42 40.450795 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 3 3 3.500000 $262.5000 $75.0000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 2 2 4.000000 $323.9200 $80.9800
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 2 2 4.000000 $323.9200 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 7 7 11.000000 $659.1200 $59.9200
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 1 1 2.000000 $119.8400 $59.9200
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 23 23 45.000000 $3644.1000 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 19 19 36.500000 $2955.7700 $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 11 11 19.500000 $1579.1100 $80.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 15 15 30.000000 $2429.4000 $80.9800
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 11 11 18.500000 $1498.1300 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 35 35 63.000000 $3774.9600 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 33 33 64.500000 $3864.8400 $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 1 1 2.000000 $161.9600 $80.9800
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 0.150000 $8.7200 $58.1100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 2 2 0.555556 $32.2900 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 0.533334 $31.0000 $58.1200
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 0.072222 $4.2000 $58.0900
SPCH -92521 EVAL OF SPEECH FLUENCY 3 3 1.450000 $84.2600 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 8.000000 $464.8800 $58.1100
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Subtotal (Total Children Is Unduplicated) 96 176 320.261112 $22708.7800 $70.9100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 14 14 11.287671 $56438.5000 $5000.0100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 52 56 50.038888 $2501.9400 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 15 18 15.972222 $798.6100 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 164 173 197.505555 $9875.2800 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 53 57 43.342065 $2167.1100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.500000 $37.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 58 59 66.523809 $3326.1900 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 39 39 44.012698 $2200.6300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 88 92 97.420636 $4871.0400 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 33 34 25.881745 $1294.0900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.700000 $17.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 98 103 107.476987 $5373.8600 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 52 55 41.432538 $2071.6200 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 5.976190 $161.3600 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 61 65 341.314281 $18430.9800 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 8 9 37.495238 $2024.7500 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 7 9 42.000000 $3415.4400 $81.3200
OCCT -97530GOGT OT SESSION BY LICENSED OT 1 1 9.000000 $731.8800 $81.3200
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 2.285714 $185.8700 $81.3200
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 5.857143 $476.3000 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 7 7 42.928571 $3490.9500 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 4 4 13.947618 $1134.2200 $81.3200
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Subtotal (Total Children Is Unduplicated) 271 802 1203.899569 $121025.6000 $100.5300
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Total 1020 1564.611476 $143734.3800 $91.8700
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Number of Children (Unduplicated) With at Least One Authorization 384