Summary Report for FSPSAs Ending During the Report Period Center: 05
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: 10-01-25 and 12-31-25 Date of Report: 01-07-26 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1196 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 22 23 19.074604 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 1.011111 $46.1900 $45.6800
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 23 24 20.085715 $46.1900 $2.3000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT COS Exit 4 4 4.000000 $200.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 3 6.000000 $450.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 2.011111 $162.8600 $80.9800
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 6 6 10.011111 $810.7000 $80.9800
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 3.000000 $242.9400 $80.9800
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 2 2 4.000000 $323.9200 $80.9800
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 3 3 2.022222 $163.7600 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 16 16 27.000000 $1617.8400 $59.9200
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 8 8 7.044444 $422.1000 $59.9200
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 72 72 141.500000 $11458.6700 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 27 27 54.000000 $4372.9200 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.000000 $161.9600 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 19 19 37.500000 $3036.7500 $80.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 34 35 69.500000 $5628.1100 $80.9800
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 10 10 19.500000 $1579.1100 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 45 46 91.500000 $5482.6800 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 85 85 169.500000 $10156.4400 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $161.9600 $80.9800
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $161.9600 $80.9800
OCTF -97168GT OT RE-EVAL EST PLAN CARE 1 1 0.027778 $1.6200 $58.1600
OCTH -97165 OT EVAL LOW COMPLEXITY 5 5 1.244443 $72.3100 $58.1000
OCTH -97167 OT EVAL HIGH COMPLEXITY 2 2 2.194444 $127.5200 $58.1100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 0.422222 $24.5300 $58.1100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 2 2 0.483333 $28.0800 $58.1100
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 1 1 0.327778 $19.0500 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 8 8 8.669842 $503.8100 $58.1100
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 1 1 0.138889 $8.0700 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 8 9 5.072223 $294.7500 $58.1100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 4 4 3.322222 $193.0500 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 3 3 2.033333 $118.1600 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 0.294444 $17.1100 $58.1000
SPCH -92521TL EVAL OF SPEECH FLUENCY 1 1 0.244444 $14.2000 $58.1000
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.394444 $22.9200 $58.1000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 11 12 7.161110 $416.1300 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 2.000000 $116.2200 $58.1100
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 3 2.666666 $154.9600 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 2 2 4.400000 $255.6800 $58.1100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 1 1.433333 $83.2900 $58.1100
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 218 404 697.619836 $49124.2300 $70.4200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 11 13 9.892998 $49465.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 34 34 35.151586 $1757.5700 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 11 13 12.000000 $600.0000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 123 127 149.734133 $7486.7400 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 36 39 40.540478 $2027.0300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 32 34 37.138889 $1856.9500 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 35 38 42.633337 $2131.6900 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 52 53 46.677780 $2333.9000 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 32 32 33.750002 $1687.5100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.900000 $47.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 60 60 63.023018 $3151.1700 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 46 49 49.655558 $2482.7900 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 12 13 20.080953 $542.1900 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 170 182 934.135710 $50443.3500 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 23 24 145.571428 $7860.8700 $54.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3 3 10.142857 $121.7100 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 11 13 89.999999 $7318.7900 $81.3200
OCCT -97530GO OT SESSION BY LICENSED OT 1 1 5.071429 $412.4100 $81.3200
OCCT -97530TL OT SESSION BY LICENSED OT 2 2 8.000000 $650.5600 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 18 18 133.785714 $10879.4600 $81.3200
PHY -97110GP PT SESSION BY LICENSED PT 3 3 15.000000 $1219.8000 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 13 14 83.785714 $6813.4600 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 4.142857 $336.9000 $81.3200
TRAV -TRAVS Travel by mile 1 1 1.000000 $0.4500 $0.4500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 220 768 1972.814440 $161627.7800 $81.9300
-------------------------------------------------------------------------------------------------------------------------------------
Total 1196 2690.519991 $210798.2000 $78.3500
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 396