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: 07-01-24 and 09-30-24 Date of Report: 04-06-25 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 575 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 29 29 30.420634 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 29 29 30.420634 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 1 1 1.000000 $59.9200 $59.9200
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $161.9600 $80.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 2 2 3.500000 $283.4300 $80.9800
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 1 1 2.000000 $161.9600 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 1.500000 $89.8800 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 3 3 6.000000 $359.5200 $59.9200
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $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 2 2 0.171004 $9.9400 $58.1100
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Subtotal (Total Children Is Unduplicated) 8 13 18.171004 $1242.8300 $68.4000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.000000 $10000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 22 26 21.172223 $1058.6200 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 10 10 8.500000 $425.0000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 135 139 162.123415 $8106.1700 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 41 42 50.823015 $2541.1500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 42 42 35.749208 $1787.4700 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 25 25 31.441271 $1572.0700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 54 55 37.223015 $1861.1500 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 26 27 11.796033 $589.8000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 79 80 81.481746 $4074.0800 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 45 45 48.158731 $2407.9400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 2.633333 $65.8300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 20 22 88.285713 $4767.4400 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 7 7 38.928571 $2102.1400 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 13.071429 $1062.9700 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 3 3 13.357143 $1086.2000 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 1 1 2.500000 $203.3000 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 2 5.357143 $435.6500 $81.3200
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Subtotal (Total Children Is Unduplicated) 165 533 654.601989 $44146.9600 $67.4400
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Total 575 703.193627 $45389.7900 $64.5500
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Number of Children (Unduplicated) With at Least One Authorization 197