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: 10-01-24 and 12-31-24 Date of Report: 03-31-25 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 867 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 23 23 2545.055556 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 3 3 376.000000 $13987.2000 $37.2000
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Subtotal (Total Children Is Unduplicated) 26 26 2921.055556 $13987.2000 $4.7900
Screening, Eval, and Assessment, Class # 02
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 2 2 4.000000 $323.9200 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 5 7 10.859208 $650.6800 $59.9200
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 17 17 34.000000 $2753.3200 $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 -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 8 8 16.000000 $1295.6800 $80.9800
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 1 1 2.000000 $161.9600 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 6 6 12.000000 $719.0400 $59.9200
OCTF -97168 OT RE-EVAL EST PLAN CARE 4 4 0.683333 $39.7100 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 4 4 5.000000 $290.5500 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 5 5 0.766668 $44.5600 $58.1200
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 4 4 0.516667 $30.0300 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 18 19 4.922220 $286.0200 $58.1100
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Subtotal (Total Children Is Unduplicated) 55 84 102.748096 $7509.5200 $73.0900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 17 18 13.993652 $699.6900 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 2 2 2.000000 $100.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 5 5 2.683333 $67.0800 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 134 137 71.155555 $3557.7800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 85 87 92.316664 $2307.9100 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 71 121 62.042855 $3102.1400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 30 57 62.711111 $1567.7800 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 22 41 21.933333 $1096.6700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 11 20 31.022223 $775.5600 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 113 116 61.016666 $3050.8300 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 1 2 0.055556 $2.7800 $50.0400
CONSP -CONSP CONSULT, SLP, PHONE 82 86 89.050000 $2226.2500 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 19 20 123.142856 $6649.7200 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 9 9 49.285714 $4007.9100 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 5 6 23.285713 $1516.3700 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 4 4 21.571428 $1754.1900 $81.3200
PHY -97110HM PT SESSION BY PT ASST 5 5 23.464286 $1528.0000 $65.1200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 17 19 92.714287 $7539.5100 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 1.000000 $81.3200 $81.3200
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Subtotal (Total Children Is Unduplicated) 230 757 845.445232 $46631.4600 $55.1600
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Total 867 3869.248884 $68128.1800 $17.6100
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Number of Children (Unduplicated) With at Least One Authorization 277