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: 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 1094 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 18 18 16.744443 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 18 18 16.744443 $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 9 9 11.033333 $893.4800 $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 4 4 8.000000 $647.8400 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 6 6 10.000000 $599.2000 $59.9200
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 12 12 20.022222 $1199.7300 $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 38 74.500000 $6033.0100 $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 36 36 71.000000 $5749.5800 $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 3 3 0.683333 $39.7100 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 2 2 1.500000 $87.1700 $58.1100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 0.066667 $3.8800 $58.1400
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 1 1 0.183333 $10.6500 $58.1000
PSTH -97161 PT EVAL LOW COMPLEXITY 9 10 7.576190 $440.2500 $58.1100
PSTH -97161TL PT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 0.122222 $7.1000 $58.1000
PSTH -97163 PT EVAL HIGH COMPLEXITY 6 8 4.483333 $260.5200 $58.1100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 4 4 3.183333 $184.9800 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 4 4 4.000000 $232.4400 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 0.122222 $7.1000 $58.1000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 7 7 4.100000 $238.2500 $58.1100
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $58.1100 $58.1100
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Subtotal (Total Children Is Unduplicated) 181 365 638.087299 $45188.6800 $70.8200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 12 12 12.931507 $64657.5000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 29 30 25.702381 $1285.1200 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 9 11 11.000000 $550.0000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 124 131 128.334123 $6416.6800 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 34 36 46.092063 $2304.6000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 25 27 24.055555 $1202.7800 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 23 23 23.385713 $1169.2800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 2 0.177778 $4.4500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 44 46 47.522221 $2376.1100 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 27 29 20.511106 $1025.5300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 59 59 49.974602 $2498.7200 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 35 36 21.615871 $1080.7800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.900000 $47.5000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 9 9 23.971429 $647.2300 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 164 189 978.157154 $52820.5100 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 20 21 114.285716 $6171.4300 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 16 19 133.671429 $10870.1700 $81.3200
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 7.142857 $580.8600 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 15 16 60.285714 $4902.4600 $81.3200
PHY -97110GP PT SESSION BY LICENSED PT 2 2 12.000000 $975.8400 $81.3200
PHY -97110GPGT PT SESSION BY LICENSED PT 1 1 11.000000 $894.5200 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 1 1 1.500000 $121.9800 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 7 7 22.571429 $1835.5100 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 12.714286 $1033.9300 $81.3200
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Subtotal (Total Children Is Unduplicated) 216 711 1790.502934 $165473.4500 $92.4200
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Total 1094 2445.334676 $210662.1300 $86.1500
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Number of Children (Unduplicated) With at Least One Authorization 311