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 552 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 21 22 18.096826 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 21 22 18.096826 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT COS Exit 4 4 4.000000 $200.0000 $50.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 1 1 0.011111 $0.9000 $80.9000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 2.000000 $119.8400 $59.9200
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 1 1 0.011111 $0.6700 $59.8600
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 3 3 6.000000 $485.8800 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.000000 $161.9600 $80.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 2 2 4.000000 $323.9200 $80.9800
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 4 4 8.000000 $479.3600 $59.9200
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 0.444444 $25.8200 $58.1000
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
PSTH -97163 PT EVAL HIGH 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) 16 23 30.466666 $2030.7900 $66.6600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 1.126027 $5630.0000 $4999.8800
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 1 1 1.666667 $45.0000 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 11 12 73.399999 $3963.6100 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 4 4 26.428572 $1427.1400 $54.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3 3 10.142857 $121.7100 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 13.285714 $1080.3900 $81.3200
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 0.714286 $58.0900 $81.3200
PHY -97110GP PT SESSION BY LICENSED PT 1 1 1.000000 $81.3200 $81.3200
TRAV -TRAVS Travel by mile 1 1 1.000000 $0.4500 $0.4500
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Subtotal (Total Children Is Unduplicated) 171 507 640.968903 $37970.5500 $59.2400
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Total 552 689.532395 $40001.3300 $58.0100
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Number of Children (Unduplicated) With at Least One Authorization 197