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: 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 706 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 22 22 1760.799999 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 5 5 697.055556 $25930.4700 $37.2000
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Subtotal (Total Children Is Unduplicated) 27 27 2457.855555 $25930.4700 $10.5500
Screening, Eval, and Assessment, Class # 02
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 4.000000 $323.9200 $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 1 1 2.000000 $119.8400 $59.9200
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 20 21 42.000000 $3401.1600 $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 13 13 26.000000 $2105.4800 $80.9800
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 3 3 6.000000 $485.8800 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 4.000000 $239.6800 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $119.8400 $59.9200
OCTF -97168 OT RE-EVAL EST PLAN CARE 8 9 10.707144 $622.2000 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 4 4 4.000000 $232.4400 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 4 4 0.733334 $42.6200 $58.1200
PSTF -97164GT PT RE-EVAL EST PLAN CARE 2 2 0.244445 $14.2100 $58.1200
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 4 5 29.705555 $1726.1900 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 12 13 3.211112 $186.6000 $58.1100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 3.714286 $215.8400 $58.1100
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Subtotal (Total Children Is Unduplicated) 49 88 150.315876 $10761.9100 $71.6000
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 15 15 11.083334 $554.1700 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 1 1 0.500000 $25.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 6 6 6.600000 $165.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 103 108 52.550003 $2627.5200 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 1 1 0.877778 $43.8900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 77 79 86.844450 $2171.1300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 56 88 54.533323 $2726.6200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 36 59 60.861109 $1521.5200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 12 24 11.911112 $595.5600 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 6 12 11.866668 $296.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 78 81 40.488889 $2024.4500 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 1 1 0.877778 $43.8900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 67 69 80.644450 $2016.1300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 6 6 39.857143 $2152.2800 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 7 7 39.571429 $3217.9500 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 4 4 30.142857 $1962.9100 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 5 5 52.857144 $4298.3400 $81.3200
PHY -97110HM PT SESSION BY PT ASST 4 4 25.571428 $1665.2200 $65.1200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 16 18 110.142859 $8956.8000 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 3 7.857144 $638.9400 $81.3200
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Subtotal (Total Children Is Unduplicated) 193 591 725.638898 $37703.9600 $51.9600
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Total 706 3333.810329 $74396.3400 $22.3200
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Number of Children (Unduplicated) With at Least One Authorization 225