Summary Report for FSPSAs Ending During the Report Period Center: 55
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 714 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 19 19 704.947620 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 4 4 1208.000000 $44937.6000 $37.2000
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Subtotal (Total Children Is Unduplicated) 23 23 1912.947620 $44937.6000 $23.4900
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT COS Exit 2 2 2.000000 $100.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 2.000000 $161.9600 $80.9800
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 9 9 18.000000 $1457.6400 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $161.9600 $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 1 1 2.000000 $161.9600 $80.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 1 1 2.000000 $161.9600 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 5 5 10.000000 $599.2000 $59.9200
OCTF -97168 OT RE-EVAL EST PLAN CARE 7 7 1.872223 $108.8000 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 8 8 5.773821 $335.5200 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 3 1.044444 $60.6900 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.322222 $18.7200 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 3 3 2.800000 $162.7100 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 0.100000 $5.8100 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 11 11 3.506348 $203.7500 $58.1100
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Subtotal (Total Children Is Unduplicated) 38 59 62.419058 $4394.6700 $70.4100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 13 14 9.683335 $484.1800 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 2 2 1.500000 $75.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 7 7 3.266667 $81.6700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 104 113 72.573813 $3628.7100 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 1 1 0.122222 $6.1100 $49.9900
CONIP -CONIP CONSULT, ITDS PHONE 51 53 54.055553 $1351.3800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 63 107 60.249206 $3012.4600 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 1 1 0.122222 $6.1100 $49.9900
CONOP -CONOP CONSULT, OT, PHONE 30 57 57.422220 $1435.5500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 21 37 18.650000 $932.5000 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 1 1 0.266667 $13.3400 $50.0100
CONPP -CONPP CONSULT, PT, PHONE 10 19 29.695238 $742.3800 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 84 90 49.619049 $2480.9600 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 1 1 0.200000 $10.0000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 53 57 50.227777 $1255.6900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 19 20 135.857139 $7336.3000 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 3.571429 $192.8600 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 6 6 33.999999 $2764.8800 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 9 10 48.428571 $3153.6700 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 5 5 25.567460 $2079.1500 $81.3200
PHY -97110HM PT SESSION BY PT ASST 4 5 37.285715 $2428.0400 $65.1200
PHY -97110HMGT PT SESSION BY PT ASST 1 1 20.571429 $1339.6100 $65.1200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 21 23 142.999998 $11628.7700 $81.3200
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Subtotal (Total Children Is Unduplicated) 201 632 856.935709 $51439.3000 $60.0300
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Total 714 2832.302387 $100771.5700 $35.5800
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Number of Children (Unduplicated) With at Least One Authorization 235