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: 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 486 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 24 24 25.122219 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 24 24 25.122219 $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
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Subtotal (Total Children Is Unduplicated) 4 6 10.000000 $683.4400 $68.3400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 1.112329 $5561.5000 $4999.8700
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 23 26 19.061110 $953.0500 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 13 16 11.416667 $570.8400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 2.933333 $73.3300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 117 123 160.417459 $8020.8600 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 34 36 46.168256 $2308.4200 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 37 38 40.529367 $2026.4800 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 29 29 34.228571 $1711.4300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 43 46 54.857145 $2742.8700 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 17 18 22.390478 $1119.5300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 71 75 69.882540 $3494.1300 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 38 40 34.305556 $1715.2800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 1.977777 $49.4400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 2 2 13.428572 $725.1400 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 8.571429 $462.8600 $54.0000
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Subtotal (Total Children Is Unduplicated) 153 456 521.280589 $31535.1400 $60.5000
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Total 486 556.402808 $32218.5800 $57.9100
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Number of Children (Unduplicated) With at Least One Authorization 177