Summary Report for FSPSAs Initiated During the Report Period Center: 55
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 1854 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 40 40 3051.322222 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 41 41 11255.758730 $418714.2200 $37.2000
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Subtotal (Total Children Is Unduplicated) 81 81 14307.080952 $418714.2200 $29.2700
Screening, Eval, and Assessment, Class # 02
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 35 35 56.936606 $4610.7300 $80.9800
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 9 9 13.147945 $1064.7300 $80.9800
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 5 5 10.000000 $809.8000 $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 17 17 30.411111 $1822.2300 $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 38 41 15.142064 $879.9100 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 1.150000 $66.8300 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 0.494444 $28.7300 $58.1000
OCTH -97167 OT EVAL HIGH COMPLEXITY 33 34 19.816669 $1151.5600 $58.1100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 2 2 3.000000 $174.3300 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 21 21 6.505555 $378.0300 $58.1100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 0.322222 $18.7200 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 5 5 4.466667 $259.5600 $58.1100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 10 11 5.800000 $337.0400 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 52 55 51.053546 $2966.7300 $58.1100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.111111 $6.4600 $58.1000
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Subtotal (Total Children Is Unduplicated) 400 746 1221.996035 $90381.6800 $73.9600
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 9 12 9.566666 $478.3300 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 2 3 2.500000 $125.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 4 4 2.722222 $68.0600 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 116 120 68.861106 $3443.0300 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 3 3 1.355556 $67.7800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 90 92 97.911108 $2447.7700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 58 106 63.833332 $3191.6600 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 1 1 0.611111 $30.5600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 30 60 62.694443 $1567.3600 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 16 30 16.433332 $821.6600 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 9 17 21.616668 $540.4200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 108 110 61.549996 $3077.4800 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 2 2 0.900000 $45.0000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 87 90 94.122218 $2353.0500 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 138 141 960.000012 $51839.9800 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 16 16 102.428573 $5531.1500 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 27 27 183.304767 $14906.3400 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 58 60 524.571437 $34160.0600 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 12 14 91.428571 $7434.9800 $81.3200
PHY -97110HM PT SESSION BY PT ASST 23 25 208.000002 $13544.9500 $65.1200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 75 80 520.714295 $42344.4500 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 4 4 35.571429 $2892.6700 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 7 7 27.071428 $2201.4500 $81.3200
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 3 4.857143 $394.9800 $81.3200
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Subtotal (Total Children Is Unduplicated) 326 1027 3162.625415 $193508.1600 $61.1900
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Total 1854 18691.702402 $702604.0700 $37.5900
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Number of Children (Unduplicated) With at Least One Authorization 513