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: 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 3492 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 55 57 31.811113 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 55 57 31.811113 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 19 19 18.495891 $897.0500 $48.5000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.000000 $7.9200 $7.9200
AUDE -92650 AEP SCR AUDITORY POTENTIAL 1 1 1.000000 $54.9000 $54.9000
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
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 1.000000 $58.1100 $58.1100
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Subtotal (Total Children Is Unduplicated) 115 139 162.034345 $9510.9100 $58.7000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.000000 $10000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 269 294 314.307275 $15715.3600 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 52 60 51.282879 $2564.1400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 37 38 34.607861 $865.2000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 160 182 354.770634 $17738.5300 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 23 27 40.499998 $2024.9900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 5 5 6.666667 $166.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 56 61 88.155550 $4407.7500 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 13 13 29.471428 $1473.5700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 5 5 5.316667 $132.9200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 59 60 110.214287 $5510.7200 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 7 7 9.600001 $480.0100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.266667 $6.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 85 89 147.876988 $7393.8700 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 13 13 25.595236 $1279.7600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 5 7.600000 $190.0000 $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 28 28 196.142861 $10591.7100 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 5 6 28.571430 $1542.8500 $54.0000
INTR -T1013 INTERPRETER 173 225 372.071429 $18603.5700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 794 1047 5885.189759 $70622.2500 $12.0000
PHY -97110 PT SESSION BY LICENSED PT 3 3 23.285715 $1893.5900 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 1 1 1.714286 $139.4100 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 3 14.380952 $1169.4500 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 3.600000 $292.7500 $81.3200
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 9.285714 $604.6800 $65.1200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 34.285714 $2788.1100 $81.3200
SPL -92508HA GROUP SPL SESSION PER CHILD 1 1 4.857143 $76.5500 $15.7600
TRAN -TRAN *FAMILY TRANSPORTATION 1 1 4.142857 $414.2900 $100.0000
TRAV -TRAVS Travel by mile 822 1115 5976.284997 $2659.4500 $0.4500
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Subtotal (Total Children Is Unduplicated) 942 3296 13784.473566 $181470.2100 $13.1600
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Total 3492 13978.319024 $190981.1200 $13.6600
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Number of Children (Unduplicated) With at Least One Authorization 1039