Summary Report for FSPSAs Initiated During the Report Period Center: 05
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: 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 1100 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 24 24 25.122219 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 24 24 25.122219 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 3 3 4.000000 $300.0000 $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 5 5 9.500000 $769.3100 $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 43 43 77.000000 $6235.4600 $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 48 48 100.357143 $6013.4000 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 90 90 175.500000 $10515.9600 $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 9 9 7.531746 $437.6700 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 4 4 1.027778 $59.7300 $58.1100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 0.150000 $8.7200 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 7 8 5.183333 $301.2000 $58.1100
PSTH -97161GT PT EVAL LOW COMPLEXITY 1 1 1.428571 $83.0200 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 3 3 1.477778 $85.8800 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 3 3 2.227778 $129.4600 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 2 2 1.238889 $71.9900 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 6 7 3.144446 $182.7300 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.205556 $11.9500 $58.1200
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 2 2 10.290476 $597.9800 $58.1100
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Subtotal (Total Children Is Unduplicated) 192 371 668.774452 $46979.7200 $70.2500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 7 7 6.112329 $30561.5000 $4999.9800
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 23 26 19.061110 $953.0500 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 13 16 11.416667 $570.8400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 2.933333 $73.3300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 117 123 160.417459 $8020.8600 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 34 36 46.168256 $2308.4200 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 37 38 40.529367 $2026.4800 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 29 29 34.228571 $1711.4300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 43 46 54.857145 $2742.8700 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 17 18 22.390478 $1119.5300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 71 75 69.882540 $3494.1300 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 38 40 34.305556 $1715.2800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 1.977777 $49.4400 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 11 11 16.623807 $448.8400 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 159 171 947.419066 $51160.5700 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 25 25 156.607145 $8456.7800 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 11 11 73.257143 $5957.2800 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 13 16 122.104760 $9929.5600 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 3 3 22.285715 $1812.2700 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 8 9 37.357143 $3037.8800 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 4.142857 $336.9000 $81.3200
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Subtotal (Total Children Is Unduplicated) 199 705 1884.078224 $136487.2400 $72.4400
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Total 1100 2577.974895 $183466.9600 $71.1700
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Number of Children (Unduplicated) With at Least One Authorization 310