Summary Report for FSPSAs Initiated During the Report Period Center: 01
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 3622 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 73 75 80.000800 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 73 75 80.000800 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 21 21 22.916569 $1111.4600 $48.5000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 1.000000 $15.1900 $15.1900
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 3 3 6.000000 $359.5200 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 8 9 17.000000 $1376.6600 $80.9800
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 4.000000 $323.9200 $80.9800
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
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Subtotal (Total Children Is Unduplicated) 150 172 179.504438 $10511.6800 $58.5600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.000000 $15000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 285 320 345.249886 $17262.5000 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 45 49 37.789044 $1889.4400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 26 26 25.219407 $630.4900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 192 204 339.692057 $16984.5700 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 12 14 10.642856 $532.1400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 0.350000 $8.7500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 71 73 113.011107 $5650.5400 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 1 1 2.133333 $106.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 3 4.666667 $116.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 67 68 127.333332 $6366.6600 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 2 2 4.300000 $215.0000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.700000 $17.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 115 117 187.854758 $9392.7200 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 6 8 3.233333 $161.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 2.683333 $67.0800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 31 33 234.571432 $12666.8600 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 12 12 94.723809 $5115.0900 $54.0000
INTR -T1013 INTERPRETER 188 261 468.611906 $23430.6000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 821 1058 6245.438152 $74945.2600 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 10.571429 $859.6700 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 7 7 58.285715 $4739.7900 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 2 3 18.285715 $1486.9900 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 4 4 29.542857 $2402.4300 $81.3200
TRAN -TRAN *FAMILY TRANSPORTATION 1 1 2.000000 $200.0000 $100.0000
TRAV -TRAVS Travel by mile 838 1102 6264.095295 $2787.5300 $0.4500
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Subtotal (Total Children Is Unduplicated) 961 3375 14633.985423 $203036.5700 $13.8700
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Total 3622 14893.490661 $213548.2500 $14.3400
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Number of Children (Unduplicated) With at Least One Authorization 1102