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 491 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 -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 1 1 2.000000 $161.9600 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 4.000000 $239.6800 $59.9200
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 1 1 2.000000 $119.8400 $59.9200
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $161.9600 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 2 2 4.000000 $323.9200 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 1 1 1.000000 $80.9800 $80.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 2 2 4.000000 $323.9200 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 3 3 5.000000 $299.6000 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 4.000000 $239.6800 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $161.9600 $80.9800
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 8.000000 $464.8800 $58.1100
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Subtotal (Total Children Is Unduplicated) 10 18 40.000000 $2740.3400 $68.5100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 9 9 8.117808 $40589.0000 $5000.0000
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
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 8 8 55.285715 $2985.4200 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 2 2 18.285714 $987.4300 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 12.000000 $975.8400 $81.3200
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 5.857143 $476.3000 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 1 1 4.000000 $325.2800 $81.3200
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Subtotal (Total Children Is Unduplicated) 157 441 553.983672 $68843.5700 $124.2700
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Total 491 618.583672 $71583.9100 $115.7200
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Number of Children (Unduplicated) With at Least One Authorization 194