Summary Report for FSPSAs Ending During the Report Period Center: 55
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 1961 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 31 1067.265079 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 40 40 11943.972221 $444315.7600 $37.2000
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Subtotal (Total Children Is Unduplicated) 71 71 13011.237300 $444315.7600 $34.1500
Screening, Eval, and Assessment, Class # 02
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 2 3.000000 $225.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 39 40 71.285693 $5772.7200 $80.9800
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 7 7 11.087671 $897.8800 $80.9800
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 8 8 13.000000 $1052.7400 $80.9800
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 9 9 18.000000 $1457.6400 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 14 14 22.043835 $1320.8600 $59.9200
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 5 6 12.000000 $719.0400 $59.9200
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 207 207 412.285714 $33386.9000 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 29 30 60.000000 $4858.8000 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 42 42 84.000000 $6802.3200 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 6 6 10.066667 $815.2000 $80.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 71 71 140.285714 $11360.3400 $80.9800
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 9 9 18.000000 $1457.6400 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 87 87 174.000000 $10426.0800 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 36 36 72.000000 $4314.2400 $59.9200
OCTF -97168 OT RE-EVAL EST PLAN CARE 52 53 20.231746 $1175.6700 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 0.638889 $37.1300 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 1.372222 $79.7400 $58.1100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 38 39 30.955557 $1798.8400 $58.1100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 28 28 8.216285 $477.4400 $58.1100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 0.088889 $5.1700 $58.1200
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.322222 $18.7200 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 9 9 7.577777 $440.3400 $58.1100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 7 7 2.677778 $155.6100 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 0.411111 $23.8900 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 70 73 69.396051 $4032.6000 $58.1100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.111111 $6.4600 $58.1000
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.133333 $65.8600 $58.1100
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 1.000000 $58.1100 $58.1100
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Subtotal (Total Children Is Unduplicated) 461 797 1268.188265 $93417.3000 $73.6600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.000000 $10000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 7 10 8.500000 $425.0000 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 2 3 2.500000 $125.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 5 5 3.133333 $78.3300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 130 138 69.361113 $3468.0700 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 1 1 0.266667 $13.3400 $50.0100
CONIP -CONIP CONSULT, ITDS PHONE 95 99 101.680953 $2542.0300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 65 114 62.261107 $3113.0400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 28 54 55.444448 $1386.1200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 19 37 17.977776 $898.8800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 7 13 14.822222 $370.5600 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 111 117 55.794446 $2789.7300 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 1 1 0.255556 $12.7800 $50.0100
CONSP -CONSP CONSULT, SLP, PHONE 90 95 96.830951 $2420.7700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 146 153 996.471423 $53809.4800 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 9 10 52.571429 $2838.8500 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 37 37 232.119045 $18875.9200 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 50 53 402.857140 $26234.0600 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 24 26 151.714284 $12337.4100 $81.3200
PHY -97110HM PT SESSION BY PT ASST 28 30 178.373811 $11615.7000 $65.1200
PHY -97110HMGT PT SESSION BY PT ASST 1 1 8.285714 $539.5600 $65.1200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 74 80 487.642851 $39655.1400 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 17.285715 $1405.6700 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 10 10 50.657142 $4119.4400 $81.3200
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 2 1.000000 $81.3200 $81.3200
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Subtotal (Total Children Is Unduplicated) 327 1093 3069.807126 $199156.1900 $64.8800
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Total 1961 17349.232691 $736889.2500 $42.4700
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Number of Children (Unduplicated) With at Least One Authorization 640