Summary Report for FSPSAs Ending During the Report Period Center: 55
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 1702 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 33 35 1746.144446 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 42 43 11285.355556 $515515.0400 $45.6800
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Subtotal (Total Children Is Unduplicated) 75 78 13031.500002 $515515.0400 $39.5600
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT COS Exit 1 2 2.000000 $100.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 4 4 6.164384 $462.3300 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 32 32 44.788052 $3626.9300 $80.9800
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 8 8 8.909589 $721.5100 $80.9800
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 3 3 4.011111 $324.8200 $80.9800
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 1 1 2.000000 $161.9600 $80.9800
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 2 2 4.000000 $323.9200 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 10 10 13.364992 $800.8200 $59.9200
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 7 7 10.153425 $608.3900 $59.9200
IPDEF -T1024TSTL F/U PSYCH AND DEV EVAL BY EI PROF 1 1 2.000000 $161.9600 $80.9800
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 201 205 410.000000 $33201.8000 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 13 13 26.000000 $2105.4800 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 81 81 162.000000 $13118.7600 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 13 13 26.000000 $2105.4800 $80.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 61 61 122.000000 $9879.5600 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 47 47 94.000000 $5632.4800 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 10 10 20.000000 $1198.4000 $59.9200
OCTF -97168 OT RE-EVAL EST PLAN CARE 35 42 8.894444 $516.8500 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.350000 $20.3400 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 31 34 22.388889 $1301.0200 $58.1100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 2 2 3.000000 $174.3300 $58.1100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 15 15 3.761111 $218.5600 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 8 9 24.083332 $1399.4700 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 61 64 31.598784 $1836.2100 $58.1100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.183333 $10.6500 $58.1000
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Subtotal (Total Children Is Unduplicated) 395 672 1055.651446 $80244.4800 $76.0100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.000000 $10000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 7 8 6.822222 $341.1100 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 4 4 4.000000 $200.0000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 118 125 68.372219 $3418.6000 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 3 3 0.566666 $28.3300 $49.9900
CONIP -CONIP CONSULT, ITDS PHONE 82 89 75.905554 $1897.6400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 41 73 30.427780 $1521.4000 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 1 1 0.277778 $13.8900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 20 41 37.472217 $936.7900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 16 30 15.288887 $764.4400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 9 17 12.300001 $307.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 107 114 65.033327 $3251.6400 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 2 2 0.422222 $21.1100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 80 88 75.794445 $1894.8600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 130 140 867.061896 $46821.3800 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 15 15 85.428571 $4613.1500 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 30 31 176.738098 $14372.3400 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 38 41 288.714285 $18801.0800 $65.1200
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 0.428571 $27.9100 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 9 10 38.000001 $3090.1600 $81.3200
PHY -97110HM PT SESSION BY PT ASST 22 22 145.428570 $9470.3200 $65.1200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 83 89 313.142854 $25464.7500 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 11.857142 $964.2300 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 3 3 14.138095 $1149.7100 $81.3200
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 5.857143 $476.3000 $81.3200
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Subtotal (Total Children Is Unduplicated) 303 952 2341.478544 $149848.6200 $64.0000
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Total 1702 16428.629992 $745608.1400 $45.3800
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Number of Children (Unduplicated) With at Least One Authorization 582