Summary Report for FSPSAs Ending During the Report Period Center: 02
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: 01-01-24 and 03-31-24 Date of Report: 04-04-25 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1268 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 2 2 0.544445 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 0.544445 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 15 15 10.271689 $498.1800 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.238356 $14.7100 $61.7200
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.238356 $3.8500 $16.1500
EXIT -EXIT COS Exit 1 1 1.000000 $50.0000 $50.0000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 1 2 4.000000 $239.6800 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 2 3 6.000000 $485.8800 $80.9800
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.483333 $28.0800 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 3 3 1.544444 $89.7500 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 3 3 2.754762 $160.0800 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 0.261111 $15.1700 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 0.544444 $31.6400 $58.1100
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Subtotal (Total Children Is Unduplicated) 24 33 27.336495 $1617.0100 $59.1500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 2.350000 $11750.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 46 46 44.126011 $2206.2800 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 6 7 5.104166 $255.2100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.233333 $30.8300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 155 182 281.880962 $14094.1000 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 1 1 0.300000 $15.0000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 2 2.000000 $50.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 90 97 126.100005 $6305.0300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.500000 $37.5000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 5 5 3.500001 $175.0100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.133333 $3.3300 $24.9900
CONSF -CONSF CONSULT, SLP, FACE TO FACE 144 150 229.766677 $11488.3800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 5 8.166667 $204.1700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 3 20.285714 $1014.2900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 6 6 32.999999 $1782.0100 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 0.866667 $46.8000 $54.0000
INTR -T1013 INTERPRETER 12 20 39.865362 $1993.2700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 167 337 1302.695242 $15632.3500 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 6 6 43.714286 $3554.8500 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 4 4 16.857143 $1370.8300 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 5 5 21.832540 $1775.4200 $81.3200
TRAV -TRAVS Travel by mile 165 350 72714.523807 $32357.9600 $0.4500
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Subtotal (Total Children Is Unduplicated) 219 1233 74899.801915 $106142.5900 $1.4200
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Total 1268 74927.682855 $107759.6000 $1.4400
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Number of Children (Unduplicated) With at Least One Authorization 224