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: 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 540 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 37 37 41.404766 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 37 37 41.404766 $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 -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 0.472222 $27.4400 $58.1100
PSTH -97163TLGT PT EVAL HIGH COMPLEXITY 1 1 0.472222 $27.4400 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.087671 $5.1000 $58.1300
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $58.1100 $58.1100
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Subtotal (Total Children Is Unduplicated) 8 14 19.032115 $1292.8700 $67.9300
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 22 25 19.027778 $951.3900 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 12 12 11.111111 $555.5600 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 125 135 137.943648 $6897.1700 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 43 45 52.375395 $2618.7600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 35 36 32.474602 $1623.7300 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 24 24 25.638888 $1281.9400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 49 52 41.403970 $2070.2100 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 23 25 21.292066 $1064.6200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 65 69 66.159523 $3307.9700 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 35 36 25.394443 $1269.7200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.300000 $32.5000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 15 17 87.695239 $4735.5500 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 6 7 42.071429 $2271.8600 $54.0000
PHY -97110 PT SESSION BY LICENSED PT 4 4 35.357143 $2875.2400 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 1 1 2.500000 $203.3000 $81.3200
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Subtotal (Total Children Is Unduplicated) 154 489 601.745235 $31759.4900 $52.7800
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Total 540 662.182116 $33052.3500 $49.9100
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Number of Children (Unduplicated) With at Least One Authorization 192