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: 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 1804 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 30 30 1311.807936 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 46 46 11646.788890 $433260.5500 $37.2000
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Subtotal (Total Children Is Unduplicated) 76 76 12958.596826 $433260.5500 $33.4300
Screening, Eval, and Assessment, Class # 02
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 7 8 14.000000 $1050.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 27 28 50.444444 $4084.9900 $80.9800
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 4 4 7.000000 $566.8600 $80.9800
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.000000 $80.9800 $80.9800
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 5 5 10.000000 $809.8000 $80.9800
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 1 1 2.000000 $161.9600 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 16 16 26.249316 $1572.8600 $59.9200
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 3 3 4.076712 $244.2800 $59.9200
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 186 187 374.000000 $30286.5200 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 25 27 54.000000 $4372.9200 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 24 24 48.000000 $3887.0400 $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 57 57 114.000000 $9231.7200 $80.9800
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 7 7 14.000000 $1133.7200 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 104 104 208.000000 $12463.3600 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 11 11 22.000000 $1318.2400 $59.9200
OCTF -97168 OT RE-EVAL EST PLAN CARE 41 45 18.453078 $1072.3200 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 3 3 0.522222 $30.3500 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 5 5 2.450000 $142.3700 $58.1100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 31 31 47.233268 $2744.7300 $58.1100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 0.172222 $10.0100 $58.1000
PSTF -97164 PT RE-EVAL EST PLAN CARE 21 21 6.971311 $405.1200 $58.1100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 0.005556 $0.3300 $58.5700
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.172222 $10.0100 $58.1000
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 4 0.227778 $13.2400 $58.1200
PSTH -97163 PT EVAL HIGH COMPLEXITY 5 5 3.883334 $225.6600 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 10 10 4.350000 $252.7800 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 0.105556 $6.1400 $58.1300
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 70 76 25.551523 $1484.8000 $58.1100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.205556 $70.0600 $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) 364 697 1073.074098 $78717.2600 $73.3600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.000000 $10000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 17 18 13.504764 $675.2500 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 2 2 2.000000 $100.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 7 7 5.383333 $134.5800 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 131 133 78.316663 $3915.8200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 95 96 116.112700 $2902.8200 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 67 112 62.483337 $3124.1900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 28 48 32.422223 $810.5600 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 16 29 17.744444 $887.2200 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 7 12 20.716667 $517.9200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 107 109 68.111108 $3405.5400 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 2 2 0.777778 $38.8900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 93 94 114.534922 $2863.3800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 152 153 1055.057148 $56973.0900 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 3 3 22.428571 $1211.1400 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 37 38 239.995237 $19516.4300 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 45 46 427.857145 $27862.0500 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 12 15 105.857141 $8608.3100 $81.3200
PHY -97110HM PT SESSION BY PT ASST 25 26 160.093651 $10425.3000 $65.1200
PHY -97110HMGT PT SESSION BY PT ASST 1 1 6.714286 $437.2400 $65.1200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 69 73 499.852383 $40647.9600 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 8.714286 $708.6500 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 9 9 45.376190 $3689.9800 $81.3200
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Subtotal (Total Children Is Unduplicated) 316 1031 3106.053977 $199456.3000 $64.2200
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Total 1804 17137.724901 $711434.1200 $41.5100
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Number of Children (Unduplicated) With at Least One Authorization 472