Summary Report for FSPSAs Ending During the Report Period Center: 05
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: 01-01-25 and 03-31-25 Date of Report: 04-06-25 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1039 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 28 30 11.722223 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 28 30 11.722223 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 2 3.000000 $225.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 8 8 13.505479 $1093.6800 $80.9800
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 1 1 2.000000 $161.9600 $80.9800
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 4 4 8.000000 $647.8400 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 10 11 17.000000 $1018.6400 $59.9200
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 7 7 10.005479 $599.5300 $59.9200
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 54 55 109.500000 $8867.3100 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 44 44 79.000000 $6397.4200 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 2 2 3.500000 $283.4300 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 18 18 36.000000 $2915.2800 $80.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 24 25 49.000000 $3968.0200 $80.9800
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 12 12 24.000000 $1943.5200 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 47 47 89.500000 $5362.8400 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 91 91 177.500000 $10635.8000 $59.9200
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 4.000000 $323.9200 $80.9800
OCTH -97165 OT EVAL LOW COMPLEXITY 5 5 1.394444 $81.0300 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 3 3 0.966667 $56.1800 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 0.305556 $17.7600 $58.1200
PSTH -97161 PT EVAL LOW COMPLEXITY 5 5 3.127777 $181.7500 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 5 5 2.783334 $161.7400 $58.1100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 0.122222 $7.1000 $58.1000
PSTH -97163TLGT PT EVAL HIGH COMPLEXITY 1 1 0.122222 $7.1000 $58.1000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 10 11 4.277778 $248.5800 $58.1100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $58.1100 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.205556 $11.9500 $58.1200
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 1.433333 $83.2900 $58.1100
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Subtotal (Total Children Is Unduplicated) 199 364 641.249847 $45358.7700 $70.7300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 9 9 9.000000 $45000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 17 18 16.794444 $839.7200 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 13 14 11.416667 $570.8400 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 109 115 124.610321 $6230.5300 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 38 39 46.246033 $2312.3100 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 35 37 35.654764 $1782.7500 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 21 21 24.988890 $1249.4500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 43 45 56.364287 $2818.2200 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 18 18 24.929364 $1246.4600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 68 74 17.722222 $886.1100 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 35 36 38.222223 $1911.1200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.000000 $25.0000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 13.128571 $354.4700 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 139 146 742.396826 $40089.4600 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 25 26 124.219050 $6707.8300 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 13 13 74.885714 $6089.7100 $81.3200
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 8.714286 $708.6500 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 15 15 75.857142 $6168.7100 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 1 1 6.000000 $487.9200 $81.3200
PHY -97110TLGT PT SESSION BY LICENSED PT 1 1 7.714286 $627.3300 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 10 10 63.857141 $5192.8700 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 1.142857 $92.9400 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 7.285714 $592.4700 $81.3200
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Subtotal (Total Children Is Unduplicated) 183 645 1532.150802 $131984.8400 $86.1400
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Total 1039 2185.122872 $177343.6100 $81.1600
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Number of Children (Unduplicated) With at Least One Authorization 366