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: 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 597 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 1 1 0.155556 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 0.155556 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 19 20 18.707806 $907.3300 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $61.7100 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 0.388889 $5.9100 $15.1900
EXIT -EXIT COS Exit 6 6 3.008220 $150.4100 $50.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.000000 $161.9600 $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 2 2 4.000000 $239.6800 $59.9200
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.388889 $22.6000 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 0.098630 $5.7300 $58.0900
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 0.388889 $22.6000 $58.1100
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.098630 $5.7300 $58.0900
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Subtotal (Total Children Is Unduplicated) 30 36 32.079953 $1703.4900 $53.1000
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 29 31 29.029073 $1451.4600 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 18 19 16.108334 $805.4200 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 134 152 210.280956 $10514.0700 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 1 1 1.533333 $76.6700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.966667 $49.1700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 76 80 113.166669 $5658.3500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.066667 $51.6700 $25.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.066667 $51.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 122 125 177.166670 $8858.3500 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 1 1 1.000000 $50.0000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.666667 $41.6700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4 5 25.714286 $1388.5700 $54.0000
INTR -T1013 INTERPRETER 25 35 84.142857 $4207.1400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 26 46 170.942856 $2051.3100 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 3 3 25.714286 $2091.0900 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 1 1 5.142857 $418.2200 $81.3200
PHY -97110HM PT SESSION BY PT ASST 1 1 9.142857 $595.3900 $65.1200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 3 21.714286 $1765.8100 $81.3200
TRAV -TRAVS Travel by mile 29 53 5155.009526 $2293.9800 $0.4500
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Subtotal (Total Children Is Unduplicated) 187 560 6053.575514 $42419.9800 $7.0100
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Total 597 6085.811023 $44123.4600 $7.2500
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Number of Children (Unduplicated) With at Least One Authorization 194