Summary Report for FSPSAs Initiated During the Report Period Center: 55
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 1827 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 20 20 2976.811112 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 36 36 8888.669048 $330658.4900 $37.2000
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Subtotal (Total Children Is Unduplicated) 56 56 11865.480160 $330658.4900 $27.8700
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 8 10 16.155555 $1211.6600 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 34 34 56.422068 $4569.0500 $80.9800
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 4 4 6.115068 $495.2000 $80.9800
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 4 4 6.011111 $486.7800 $80.9800
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 11 11 22.000000 $1781.5600 $80.9800
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 2 2 4.000000 $323.9200 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 15 15 26.191781 $1569.4100 $59.9200
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 3 3 2.180821 $130.6700 $59.9200
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 184 186 370.066667 $29968.0000 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 19 20 40.000000 $3239.2000 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 41 41 82.000000 $6640.3600 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 5 5 10.000000 $809.8000 $80.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 38 38 74.066667 $5997.9200 $80.9800
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 11 11 22.000000 $1781.5600 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 103 103 206.000000 $12343.5200 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 15 15 30.000000 $1797.6000 $59.9200
OCTF -97168 OT RE-EVAL EST PLAN CARE 37 38 10.511111 $610.8000 $58.1100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 4 4 1.011111 $58.7500 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 25 25 18.612708 $1081.5700 $58.1100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 3 3 2.100000 $122.0300 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 13 13 3.547640 $206.1500 $58.1100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 2 2 0.288889 $16.7900 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.138889 $8.0700 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 1.188889 $69.0900 $58.1100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 2 2 1.466667 $85.2300 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 12 12 9.744444 $566.2500 $58.1100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 13 13 4.116668 $239.2300 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 0.183333 $10.6500 $58.1000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 58 65 15.759896 $915.8200 $58.1100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 4.000000 $232.4400 $58.1100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 0.644445 $37.4500 $58.1100
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 1.000000 $58.1100 $58.1100
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Subtotal (Total Children Is Unduplicated) 378 694 1055.524428 $78004.8000 $73.9000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.000000 $10000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 13 14 9.561112 $478.0600 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 2 2 1.500000 $75.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 8 8 4.633333 $115.8300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 120 123 63.480153 $3173.9800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 82 85 92.222224 $2305.5600 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 70 116 57.994446 $2899.7300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 40 71 76.155556 $1903.8900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 18 33 17.972223 $898.6200 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 1 1 0.144444 $7.2200 $49.9800
CONPP -CONPP CONSULT, PT, PHONE 10 18 25.833335 $645.8400 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 99 104 55.569043 $2778.4300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 79 82 89.650000 $2241.2500 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 138 143 1074.714305 $58034.5500 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 8 8 58.000000 $3132.0100 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 45 49 262.885719 $21377.8700 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 59 64 434.571433 $28299.2800 $65.1200
OCCT -97530TLHM OT SESSION BY OT ASST 1 1 5.285714 $344.2000 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 26 26 162.372224 $13204.1000 $81.3200
PHY -97110HM PT SESSION BY PT ASST 24 24 147.000003 $9572.6300 $65.1200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 85 88 425.142868 $34572.5400 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 4 13.642858 $1109.4300 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 11 11 48.723812 $3962.2100 $81.3200
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Subtotal (Total Children Is Unduplicated) 343 1077 3129.054805 $201132.2300 $64.2800
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Total 1827 16050.059393 $609795.5300 $37.9900
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Number of Children (Unduplicated) With at Least One Authorization 500