Summary Report for FSPSAs Ending During the Report Period Center: 01
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 3732 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 69 70 79.666668 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 69 70 79.666668 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 17 18 17.685388 $857.7500 $48.5000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 2 2 1.227778 $18.6500 $15.1900
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.000000 $7.9200 $7.9200
EXIT -EXIT COS Exit 110 111 80.587869 $4029.3900 $50.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 3 3 6.000000 $485.8800 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 2 2 4.000000 $323.9200 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 3 3 6.000000 $485.8800 $80.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 2 2 4.000000 $323.9200 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 14 14 27.000000 $1617.8400 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 4 4 8.000000 $479.3600 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 9 10 19.000000 $1538.6200 $80.9800
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 4.000000 $323.9200 $80.9800
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
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Subtotal (Total Children Is Unduplicated) 151 173 179.501035 $10551.1500 $58.7800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 5 4.063014 $20315.0000 $4999.9800
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 286 324 351.849885 $17592.5000 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 47 51 42.255711 $2112.7700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 29 29 30.086074 $752.1500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 175 184 348.121434 $17406.1000 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 21 22 31.680954 $1584.0600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 2 4.200000 $105.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 69 70 134.328570 $6716.4300 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 7 7 12.233333 $611.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.466667 $36.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 75 76 125.977775 $6298.8800 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 7 7 6.200000 $310.0000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 3 3 6.166666 $154.1700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 106 112 196.671432 $9833.5900 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 12 14 20.932541 $1046.6300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 5 8.399999 $210.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 32 35 223.314285 $12058.9800 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 20 22 151.038093 $8156.0700 $54.0000
INTR -T1013 INTERPRETER 192 256 443.811904 $22190.6100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 862 1102 6976.001558 $83712.0600 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 1.142857 $92.9400 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 4 4 23.142856 $1881.9800 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 2 2 18.428571 $1498.6100 $81.3200
PHY -97110TL PT SESSION BY LICENSED PT 1 1 0.571429 $46.4700 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 5 5 40.752380 $3313.9900 $81.3200
TRAN -TRAN *FAMILY TRANSPORTATION 1 1 2.000000 $200.0000 $100.0000
TRAV -TRAVS Travel by mile 901 1148 7019.682511 $3123.7600 $0.4500
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Subtotal (Total Children Is Unduplicated) 1077 3489 16224.520499 $221361.0300 $13.6400
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Total 3732 16483.688202 $231912.1800 $14.0700
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Number of Children (Unduplicated) With at Least One Authorization 1151