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: 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 789 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 1.744444 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 1.744444 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 18 18 11.123972 $539.5100 $48.5000
EXIT -EXIT COS Exit 7 7 7.000000 $350.0000 $50.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $161.9600 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 2 2 4.000000 $323.9200 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $119.8400 $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 2 3 4.000000 $323.9200 $80.9800
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 7.857143 $456.5800 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.205556 $11.9500 $58.1200
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.205556 $11.9500 $58.1200
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 0.333333 $19.3700 $58.1000
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.221918 $12.8900 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.205556 $70.0600 $58.1100
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Subtotal (Total Children Is Unduplicated) 31 42 46.153034 $2761.4700 $59.8300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.244444 $1222.0000 $4999.1000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 49 50 52.742195 $2637.1000 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 10 10 12.250000 $612.5000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 144 169 270.699991 $13534.9600 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 3 3 5.499999 $275.0000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 79 85 156.914280 $7845.7000 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 1 1 1.800000 $90.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.133333 $53.3300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 1.633333 $81.6700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.400000 $60.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 138 144 286.647613 $14332.3500 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 1 1 2.233333 $111.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 5 10.376190 $259.4100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 16 16 102.857143 $5554.2900 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 9.571429 $516.8600 $54.0000
INTR -T1013 INTERPRETER 20 29 51.414773 $2570.7500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 53 96 290.519043 $3486.2300 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 4 4 32.571428 $2648.7100 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 2 2 13.142857 $1068.7700 $81.3200
PHY -97110HM PT SESSION BY PT ASST 1 1 9.428571 $613.9900 $65.1200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 5 5 37.714286 $3066.9200 $81.3200
TRAV -TRAVS Travel by mile 54 118 13021.340575 $5794.5000 $0.4500
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Subtotal (Total Children Is Unduplicated) 213 745 14374.134816 $66436.6700 $4.6200
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Total 789 14422.032294 $69198.1400 $4.8000
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Number of Children (Unduplicated) With at Least One Authorization 225