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 524 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
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Subtotal (Total Children Is Unduplicated) 22 22 8.544444 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT COS Exit 2 2 2.000000 $100.0000 $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 -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 4.285714 $256.8000 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 4 4 8.000000 $479.3600 $59.9200
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Subtotal (Total Children Is Unduplicated) 11 17 28.307936 $1929.3200 $68.1500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 2.150685 $10753.5000 $5000.0300
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 1 1 1.400000 $37.8000 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 15 15 91.604759 $4946.6600 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 6 6 23.285714 $1257.4300 $54.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1 1 1.000000 $12.0000 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 3.142857 $255.5800 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 1 1 3.857143 $313.6600 $81.3200
PHY -97110GP PT SESSION BY LICENSED PT 1 1 3.857143 $313.6600 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 3.142857 $255.5800 $81.3200
TRAV -TRAVS Travel by mile 1 1 1.000000 $0.4500 $0.4500
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Subtotal (Total Children Is Unduplicated) 163 485 646.281614 $43614.6600 $67.4900
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Total 524 683.133994 $45543.9900 $66.6700
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Number of Children (Unduplicated) With at Least One Authorization 186