Summary Report for FSPSAs Initiated During the Report Period Center: 05
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: 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 1112 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 22 8.544444 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 -1.766667 $-80.7000 $45.6800
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Subtotal (Total Children Is Unduplicated) 24 24 6.777777 $-80.7000 $-11.9100
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT COS Exit 2 2 2.000000 $100.0000 $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 1 1 2.000000 $161.9600 $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 2 2 0.022222 $1.8000 $80.9000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 12 12 20.000000 $1198.4000 $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 26 26 52.000000 $4210.9600 $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 20 20 39.500000 $3198.7100 $80.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 32 33 65.500000 $5304.1900 $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 48 49 99.214285 $5944.9200 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 84 84 167.500000 $10036.6000 $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 -97168 OT RE-EVAL EST PLAN CARE 1 1 0.094444 $5.4900 $58.0800
OCTH -97165 OT EVAL LOW COMPLEXITY 5 5 4.666667 $271.1800 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 3 4 0.750001 $43.5900 $58.1200
OCTH -97167GT OT EVAL HIGH COMPLEXITY 2 2 0.533333 $30.9900 $58.1100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 2 2 0.583333 $33.9000 $58.1100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 0.316667 $18.4000 $58.1200
PSTH -97161 PT EVAL LOW COMPLEXITY 4 4 0.533333 $30.9900 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 4 4 1.783333 $103.6300 $58.1100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 0.283333 $16.4600 $58.1000
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 5 5 1.544444 $89.7500 $58.1100
SPCH -92521TL EVAL OF SPEECH FLUENCY 2 2 3.266667 $189.8300 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 6 6 5.172222 $300.5600 $58.1100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.305556 $17.7600 $58.1200
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $58.1100 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 3.000000 $174.3300 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 2 2 8.823810 $512.7500 $58.1100
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Subtotal (Total Children Is Unduplicated) 191 380 677.460316 $47806.5900 $70.5700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 13 15 13.186377 $65932.0000 $5000.0100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 23 23 23.044444 $1152.2200 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 10 12 9.772222 $488.6100 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 123 125 150.522216 $7526.1000 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 39 40 52.066666 $2603.3300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 38 38 42.419838 $2120.9800 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 37 39 52.579362 $2628.9600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 41 42 43.066666 $2153.3300 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 29 29 43.611111 $2180.5600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 62 62 36.886504 $1844.3100 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 41 41 52.926983 $2646.3500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 4.944444 $123.6100 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 7 7 21.033333 $567.9000 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 165 167 1005.757126 $54310.9200 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 20 21 139.857140 $7552.3000 $54.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1 1 1.000000 $12.0000 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 9 10 65.428571 $5320.6500 $81.3200
OCCT -97530GO OT SESSION BY LICENSED OT 1 1 2.857143 $232.3400 $81.3200
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 10.000000 $813.2000 $81.3200
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 7.285714 $592.4700 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 13 14 99.071428 $8056.4900 $81.3200
PHY -97110GP PT SESSION BY LICENSED PT 3 3 36.428572 $2962.3700 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 11 11 64.561902 $5250.1700 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 1.633333 $132.8200 $81.3200
TRAV -TRAVS Travel by mile 1 1 1.000000 $0.4500 $0.4500
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Subtotal (Total Children Is Unduplicated) 207 708 1980.941095 $177204.4100 $89.4500
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Total 1112 2665.179188 $224930.3000 $84.4000
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Number of Children (Unduplicated) With at Least One Authorization 310