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: 01-01-25 and 03-31-25 Date of Report: 04-06-25 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 470 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 27 29 10.944445 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 27 29 10.944445 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 2.000000 $119.8400 $59.9200
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $161.9600 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.000000 $161.9600 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 4.000000 $239.6800 $59.9200
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 0.122222 $7.1000 $58.1000
PSTH -97163TLGT PT EVAL HIGH COMPLEXITY 1 1 0.122222 $7.1000 $58.1000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 5 8 10.244444 $697.6400 $68.1000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 17 18 16.794444 $839.7200 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 13 14 11.416667 $570.8400 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 109 115 124.610321 $6230.5300 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 38 39 46.246033 $2312.3100 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 35 37 35.654764 $1782.7500 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 21 21 24.988890 $1249.4500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 43 45 56.364287 $2818.2200 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 18 18 24.929364 $1246.4600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 68 74 17.722222 $886.1100 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 35 36 38.222223 $1911.1200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.000000 $25.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 9 9 41.619048 $2247.4200 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 4 4 23.428572 $1265.1400 $54.0000
PHY -97110 PT SESSION BY LICENSED PT 1 1 3.142857 $255.5800 $81.3200
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 144 433 467.139692 $28640.6300 $61.3100
-------------------------------------------------------------------------------------------------------------------------------------
Total 470 488.328581 $29338.2700 $60.0800
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 171