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: 07-01-24 and 09-30-24 Date of Report: 04-06-25 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1126 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 29 29 30.420634 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 29 29 30.420634 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 3 3 4.000000 $300.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 4 4 8.000000 $647.8400 $80.9800
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 6 6 8.022222 $649.6400 $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 1 1 2.000000 $161.9600 $80.9800
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 7 7 12.011111 $972.6600 $80.9800
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 2 2 2.500000 $202.4500 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 8 8 10.488889 $628.4900 $59.9200
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 12 12 17.511111 $1049.2700 $59.9200
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 37 38 75.000000 $6073.5000 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 41 41 80.500000 $6518.8900 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 3 3 6.000000 $485.8800 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 10 10 18.000000 $1457.6400 $80.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 38 38 74.000000 $5992.5200 $80.9800
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 18 18 35.500000 $2874.7900 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 39 39 74.500000 $4464.0400 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 56 56 106.500000 $6381.4800 $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
OCTH -97165 OT EVAL LOW COMPLEXITY 4 4 1.194444 $69.4100 $58.1100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 0.055556 $3.2300 $58.1600
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.061111 $3.5500 $58.1000
OCTH -97167 OT EVAL HIGH COMPLEXITY 3 3 2.272222 $132.0400 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 7 8 6.533334 $379.6600 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 4 4 1.393531 $80.9800 $58.1100
PSTH -97163TLGT PT EVAL HIGH COMPLEXITY 1 1 0.633333 $36.8000 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 10 11 8.672222 $503.9400 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 1.576560 $91.6200 $58.1100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.005556 $58.4400 $58.1100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.255556 $14.8500 $58.1200
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Subtotal (Total Children Is Unduplicated) 181 333 570.197869 $41208.2200 $72.2700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 8 8 6.134247 $30671.5000 $5000.0400
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 22 26 21.172223 $1058.6200 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 10 10 8.500000 $425.0000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 135 139 162.123415 $8106.1700 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 41 42 50.823015 $2541.1500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 42 42 35.749208 $1787.4700 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 25 25 31.441271 $1572.0700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 54 55 37.223015 $1861.1500 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 26 27 11.796033 $589.8000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 79 80 81.481746 $4074.0800 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 45 45 48.158731 $2407.9400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 2.633333 $65.8300 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 3.500000 $94.5000 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 158 168 940.464275 $50785.1400 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 34 35 164.599999 $8888.4100 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 15 15 95.928571 $7800.9100 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 19 21 89.500001 $7278.1300 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 3 3 10.500000 $853.8600 $81.3200
PHY -97110TL PT SESSION BY LICENSED PT 1 1 6.285714 $511.1500 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 14 14 99.295240 $8074.7000 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 28.000001 $2276.9500 $81.3200
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Subtotal (Total Children Is Unduplicated) 207 764 1935.310038 $141724.5200 $73.2300
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Total 1126 2535.928541 $182932.7400 $72.1400
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Number of Children (Unduplicated) With at Least One Authorization 358