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 801 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 3 3 -1223.700000 $-45521.6400 $37.2000
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Subtotal (Total Children Is Unduplicated) 23 23 1753.111112 $-45521.6400 $-25.9700
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 -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $161.9600 $80.9800
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 2.000000 $161.9600 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 4.164384 $249.5300 $59.9200
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 6 6 1.850000 $107.5000 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.372222 $21.6300 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 4 4 2.273821 $132.1300 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 4 4 0.988888 $57.4600 $58.1000
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 0.111111 $6.4600 $58.1000
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.188889 $10.9800 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 0.222222 $12.9100 $58.1000
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 0.600000 $34.8700 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 10 12 2.222223 $129.1400 $58.1100
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Subtotal (Total Children Is Unduplicated) 35 61 61.993760 $4423.2300 $71.3500
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 119 122 62.802375 $3140.0900 $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 98 103 54.891265 $2744.5400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 79 82 89.650000 $2241.2500 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 15 15 167.000001 $9017.9900 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 2.714286 $146.5700 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 8 8 53.142858 $4321.5800 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 8 9 58.285715 $3795.5600 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 5 5 23.229365 $1889.0100 $81.3200
PHY -97110HM PT SESSION BY PT ASST 4 4 26.142858 $1702.4300 $65.1200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 18 18 122.571429 $9967.5100 $81.3200
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Subtotal (Total Children Is Unduplicated) 226 717 948.446825 $58296.2700 $61.4600
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Total 801 2763.551697 $17197.8600 $6.2200
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Number of Children (Unduplicated) With at Least One Authorization 254