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: 10-01-23 and 12-31-23 Date of Report: 01-14-24 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 598 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 15 15 16.644443 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 15 15 16.644443 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TLTSGT F/U PHYC AND DEV EVAL BY EI PROF 1 1 0.005556 $0.4200 $75.5900
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 2 2 3.500000 $262.5000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 4.000000 $222.0000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 2 3 5.500000 $305.2500 $55.5000
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Subtotal (Total Children Is Unduplicated) 9 16 29.005556 $1912.1700 $65.9200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 24 28 24.844444 $1242.2200 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 8 10 10.600000 $530.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 156 164 193.923801 $9696.1500 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 42 45 45.549204 $2277.4500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 63 68 60.162697 $3008.1300 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 41 44 56.708728 $2835.4200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 41 43 46.300396 $2315.0200 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 21 21 23.191665 $1159.5800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 70 74 75.696423 $3784.7800 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 40 42 53.443252 $2672.1400 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 3 15.357143 $767.8600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 15 16 122.714286 $6135.7100 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 4 5 25.000001 $1250.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 12.714286 $914.9200 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 1 1 0.928571 $66.8200 $71.9600
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Subtotal (Total Children Is Unduplicated) 191 567 769.134897 $43681.1800 $56.7900
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Total 598 814.784896 $45593.3500 $55.9600
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Number of Children (Unduplicated) With at Least One Authorization 213