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 774 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 39 39 3051.077778 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 752.000000 $27974.4000 $37.2000
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Subtotal (Total Children Is Unduplicated) 41 41 3803.077778 $27974.4000 $7.3600
Screening, Eval, and Assessment, Class # 02
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 6.000000 $485.8800 $80.9800
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 2 2 4.000000 $323.9200 $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 4 4 8.000000 $479.3600 $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 8 8 16.000000 $1295.6800 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 3 3 6.000000 $485.8800 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 2 2 4.000000 $323.9200 $80.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 3 3 6.000000 $485.8800 $80.9800
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 3 3 6.000000 $485.8800 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 4 4 8.000000 $479.3600 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 4.000000 $239.6800 $59.9200
OCTF -97168 OT RE-EVAL EST PLAN CARE 4 4 1.977779 $114.9400 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 5 5 4.177778 $242.7700 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 3 3 0.288889 $16.7900 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 1 2 2.000000 $116.2200 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 0.677778 $39.3900 $58.1100
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Subtotal (Total Children Is Unduplicated) 33 54 81.122224 $5897.3400 $72.7000
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 114 117 66.516662 $3325.8100 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 3 3 1.355556 $67.7800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 89 91 97.633330 $2440.8300 $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 107 109 61.094440 $3054.7000 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 2 2 0.900000 $45.0000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 86 89 93.844440 $2346.1000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 6 6 44.571429 $2406.8600 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 12.000000 $648.0000 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 3 3 25.142858 $2044.6200 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 8 8 47.714287 $3107.1500 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 3 3 14.428572 $1173.3300 $81.3200
PHY -97110HM PT SESSION BY PT ASST 3 4 18.714286 $1218.6800 $65.1200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 9 9 57.285715 $4658.4600 $81.3200
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 0.428571 $34.8500 $81.3300
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Subtotal (Total Children Is Unduplicated) 210 679 721.607920 $33395.2100 $46.2800
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Total 774 4605.807922 $67266.9500 $14.6000
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Number of Children (Unduplicated) With at Least One Authorization 259