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 496 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 -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
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 0.066667 $3.8800 $58.1400
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $58.1100 $58.1100
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Subtotal (Total Children Is Unduplicated) 11 20 34.066667 $2395.5600 $70.3200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 9 9 8.131507 $40657.5000 $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 2 2 4.233333 $114.3000 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 10 11 49.147620 $2653.9700 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 2 2 6.928572 $374.1400 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 2 12.857143 $1045.5400 $81.3200
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 7.142857 $580.8600 $81.3200
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Subtotal (Total Children Is Unduplicated) 165 458 488.712445 $65387.8300 $133.8000
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Total 496 539.523555 $67783.3800 $125.6400
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Number of Children (Unduplicated) With at Least One Authorization 186