Summary Report for FSPSAs Initiated During the Report Period Center: 02
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 559 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 3 3 1.244444 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 1.244444 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 15 15 8.078996 $391.8300 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $61.7100 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 0.111111 $1.6900 $15.1900
EXIT -EXIT COS Exit 4 4 1.008220 $50.4100 $49.9900
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 0.111111 $6.4600 $58.1000
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 0.111111 $6.4600 $58.1000
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Subtotal (Total Children Is Unduplicated) 23 27 18.420549 $1040.0300 $56.4600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.366667 $1833.5000 $5000.4500
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 34 35 43.617962 $2180.9000 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 18 19 16.108334 $805.4200 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 150 163 267.071434 $13353.5900 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 2 2 3.833334 $191.6700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 91 93 150.814286 $7540.7200 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 1 1 2.300000 $115.0000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 3 5.066667 $126.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 135 136 235.861905 $11793.1000 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 2 2 3.300000 $165.0000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.333333 $33.3300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 5 6 35.285715 $1905.4200 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 9.428571 $509.1400 $54.0000
INTR -T1013 INTERPRETER 24 33 68.000000 $3400.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 4 7 12.466666 $149.6000 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 10.428572 $848.0500 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 2.857143 $232.3400 $81.3200
TRAV -TRAVS Travel by mile 12 23 1702.476191 $757.6000 $0.4500
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Subtotal (Total Children Is Unduplicated) 197 529 2570.616780 $45941.0400 $17.8700
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Total 559 2590.281773 $46981.0700 $18.1400
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Number of Children (Unduplicated) With at Least One Authorization 207