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: 04-01-25 and 06-30-25 Date of Report: 07-19-25 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1069 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 31 32 24.600000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 31 32 24.600000 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 8 11 17.000000 $1275.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 7 7 8.033333 $650.5400 $80.9800
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 4 4 8.000000 $647.8400 $80.9800
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 4 5 8.011111 $648.7400 $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 4 4 7.000000 $419.4400 $59.9200
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 11 11 18.022222 $1079.8900 $59.9200
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 51 51 101.000000 $8178.9800 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 38 39 76.500000 $6194.9700 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 2 2 4.000000 $323.9200 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 12 12 22.000000 $1781.5600 $80.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 35 35 69.000000 $5587.6200 $80.9800
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 6 6 11.000000 $890.7800 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 41 42 82.000000 $4913.4400 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 81 81 159.500000 $9557.2400 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $161.9600 $80.9800
OCTH -97165 OT EVAL LOW COMPLEXITY 7 7 2.511111 $145.9200 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 3 3 0.850000 $49.3900 $58.1100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 0.322222 $18.7200 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 7 8 5.455556 $317.0200 $58.1100
PSTH -97161TL PT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 4 4 2.055556 $119.4500 $58.1100
PSTH -97163TLGT PT EVAL HIGH COMPLEXITY 1 1 0.161111 $9.3600 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 1.888889 $109.7600 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 6 6 1.494444 $86.8400 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.488889 $28.4100 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 8.000000 $464.8800 $58.1100
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Subtotal (Total Children Is Unduplicated) 190 351 626.794444 $44489.1000 $70.9800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 14 14 10.758447 $53792.0000 $4999.9800
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 26 27 25.333332 $1266.6600 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 8 10 9.222222 $461.1100 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 107 112 138.346029 $6917.2900 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 35 37 30.038888 $1501.9400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 42 43 47.934920 $2396.7400 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 25 25 32.310317 $1615.5100 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 50 50 58.085714 $2904.2800 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 18 18 13.166665 $658.3300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.700000 $17.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 59 62 72.021430 $3601.0800 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 32 34 23.277775 $1163.8800 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 8 8 12.199998 $329.3900 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 145 163 751.211905 $40565.4400 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 24 24 160.678275 $8676.6200 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 18 20 122.757142 $9982.6000 $81.3200
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 5.857143 $476.3000 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 17 18 92.000000 $7481.4300 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 4 4 12.190476 $991.3200 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 14 14 67.357143 $5477.4900 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 6.000000 $487.9200 $81.3200
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Subtotal (Total Children Is Unduplicated) 202 686 1691.447821 $150764.8200 $89.1300
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Total 1069 2342.842265 $195253.9200 $83.3400
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Number of Children (Unduplicated) With at Least One Authorization 370