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: 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 3478 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 58 60 108.629366 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 58 60 108.629366 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 23 23 24.167124 $1172.1000 $48.5000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 1.000000 $15.1900 $15.1900
EXIT -EXIT COS Exit 75 81 72.538454 $3626.9300 $50.0000
IPDEF -IPDEF_NM F/U PSYCH & DEV EVAL BY NON-MED PRO 1 1 2.000000 $111.0000 $55.5000
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 3 3 4.000000 $323.9200 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 2 2 4.000000 $323.9200 $80.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 1 1 2.000000 $161.9600 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 9 10 20.000000 $1198.4000 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 5 5 8.000000 $479.3600 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 9 11 22.000000 $1781.5600 $80.9800
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 118 143 167.705578 $9796.4400 $58.4100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 6 5.041096 $25205.5000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 269 294 314.773942 $15738.6900 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 52 60 51.282879 $2564.1400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 36 37 33.841194 $846.0300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 177 198 371.551584 $18577.5700 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 8 10 8.649998 $432.4900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 5 5 5.422222 $135.5600 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 66 71 137.076189 $6853.8100 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 5 5 10.966666 $548.3300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 4 5 5.616667 $140.4200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 58 58 96.633333 $4831.6700 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 3 3 3.400000 $170.0000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 4.766666 $119.1700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 98 102 177.564284 $8878.2100 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 3 3 2.933333 $146.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 2.888889 $72.2200 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 2.428571 $121.4300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 27 28 158.787299 $8574.5300 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 8 8 75.571428 $4080.8600 $54.0000
INTR -T1013 INTERPRETER 176 226 407.000001 $20350.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 774 1035 6027.249178 $72326.9900 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 5.000000 $406.6000 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 9 9 46.142858 $3752.3300 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 1 1 11.142857 $906.1400 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 4 4 8.447620 $686.9700 $81.3200
TRAV -TRAVS Travel by mile 830 1101 6098.563465 $2713.8600 $0.4400
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 998 3275 14072.742219 $199180.1500 $14.1500
-------------------------------------------------------------------------------------------------------------------------------------
Total 3478 14349.077163 $208976.5900 $14.5600
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 1059