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
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1080 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 38 38 41.626988 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 38 38 41.626988 $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 8 8 13.011111 $1053.6400 $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 12.011111 $719.7100 $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 42 42 82.500000 $6680.8500 $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 9 9 16.000000 $1295.6800 $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 38 38 72.500000 $4344.2000 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 57 57 108.500000 $6501.3200 $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 3 3 0.505555 $29.3700 $58.1000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.266667 $15.5000 $58.1200
OCTH -97167 OT EVAL HIGH COMPLEXITY 4 4 3.177779 $184.6700 $58.1100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 0.466667 $27.1200 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 0.194444 $11.3000 $58.1000
PSTH -97161 PT EVAL LOW COMPLEXITY 5 6 3.900001 $226.6300 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 6 6 4.244445 $246.6500 $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 2 2 2.000000 $116.2200 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 9 10 4.098782 $238.1800 $58.1100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.505556 $87.4900 $58.1100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.311111 $18.0800 $58.1100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.744444 $101.3700 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 2.000000 $116.2200 $58.1100
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Subtotal (Total Children Is Unduplicated) 172 337 574.426561 $41479.5700 $72.2100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 7 7 7.000000 $35000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 22 25 19.027778 $951.3900 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 12 12 11.111111 $555.5600 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 125 135 137.943648 $6897.1700 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 43 45 52.375395 $2618.7600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 35 36 32.474602 $1623.7300 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 24 24 25.638888 $1281.9400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 49 52 41.403970 $2070.2100 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 23 25 21.292066 $1064.6200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 65 69 66.159523 $3307.9700 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 35 36 25.394443 $1269.7200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.300000 $32.5000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 5 5 14.828572 $400.3700 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 146 156 877.442873 $47381.8700 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 34 35 199.690479 $10783.2700 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 12 12 58.500002 $4757.2000 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 13 14 89.142857 $7249.0900 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 1 1 2.500000 $203.3000 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 11 11 62.142858 $5053.4600 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 20.142857 $1638.0200 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 2 2 1.000000 $81.3200 $81.3200
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Subtotal (Total Children Is Unduplicated) 199 705 1766.511922 $134221.4500 $75.9800
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Total 1080 2382.565471 $175701.0200 $73.7400
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Number of Children (Unduplicated) With at Least One Authorization 299