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: 04-01-25 and 06-30-25 Date of Report: 07-19-25 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 3406 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 57 60 42.822222 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 57 60 42.822222 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 19 20 14.764385 $716.0800 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 2.000000 $123.4200 $61.7100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.000000 $7.9200 $7.9200
EXIT -EXIT COS Exit 83 89 78.255480 $3912.7700 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 2 4.000000 $300.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $161.9600 $80.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 1 1 2.000000 $161.9600 $80.9800
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 1 1 2.000000 $161.9600 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 4.000000 $239.6800 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 4.000000 $239.6800 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $161.9600 $80.9800
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 2.000000 $116.2200 $58.1100
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 108 124 118.019865 $6303.6100 $53.4100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 4 4.000000 $20000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 233 255 260.872573 $13043.6400 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 62 69 61.030140 $3051.4900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 32 32 28.202740 $705.0700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 169 177 314.557928 $15727.8500 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 16 16 26.252381 $1312.6200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 8 8 9.233333 $230.8300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 53 55 88.833335 $4441.6800 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 13 13 24.180952 $1209.0500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 1.866666 $46.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 64 69 120.849999 $6042.5000 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 6 6 8.800000 $440.0000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 78 82 135.196028 $6759.7800 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 9 9 22.433333 $1121.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 9.399999 $235.0000 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 2.571429 $128.5700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 31 32 239.857141 $12952.2800 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 6 7 42.285714 $2283.4300 $54.0000
INTR -T1013 INTERPRETER 217 264 447.683333 $22384.1800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 806 1034 5919.141219 $71029.7300 $12.0000
PHY -97110 PT SESSION BY LICENSED PT 2 2 35.714286 $2904.2800 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 1 1 10.285714 $836.4300 $81.3200
PHY -97110TLGT PT SESSION BY LICENSED PT 1 1 1.428571 $116.1700 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 3 20.142857 $1638.0200 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 6.295238 $511.9300 $81.3200
TRAV -TRAVS Travel by mile 843 1074 6004.741221 $2672.1100 $0.4400
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 1055 3222 13845.856130 $191824.9500 $13.8500
-------------------------------------------------------------------------------------------------------------------------------------
Total 3406 14006.698217 $198128.5600 $14.1500
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 1109