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: 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 607 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 5 5 9.852380 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 5 5 9.852380 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 24 24 25.057121 $1215.2700 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $61.7100 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 0.283333 $4.3000 $15.1900
EXIT -EXIT COS Exit 1 1 0.002740 $0.1400 $49.2700
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 0.005479 $0.4500 $81.2900
IPDEI -T1024GOUK 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 0.005479 $0.3300 $60.1600
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 2 3 6.000000 $485.8800 $80.9800
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 4.000000 $323.9200 $80.9800
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 1.283333 $74.5700 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.233333 $13.5600 $58.1000
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 0.283333 $16.4600 $58.1000
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 0.233333 $13.5600 $58.1000
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Subtotal (Total Children Is Unduplicated) 32 42 44.387484 $2611.7900 $58.8400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.202740 $1013.5000 $4999.0100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 38 39 39.757870 $1987.8800 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 7 7 10.000000 $500.0000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 158 180 301.285715 $15064.2800 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 3 4 4.333333 $216.6700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 2.333333 $58.3300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 95 99 146.519047 $7325.9500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 4 4 2.233332 $111.6600 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 1 1 0.366667 $18.3400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 3.033333 $75.8300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 131 135 195.995240 $9799.7700 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 1 1 0.366667 $18.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 2 2.766667 $69.1700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 9 10 48.571427 $2622.8600 $54.0000
INTR -T1013 INTERPRETER 22 34 72.535714 $3626.7900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 8 10 24.647620 $295.7700 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 3 3 22.142857 $1800.6500 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 2 13.285714 $1080.3900 $81.3200
TRAV -TRAVS Travel by mile 15 26 2062.142856 $917.6500 $0.4500
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Subtotal (Total Children Is Unduplicated) 214 560 2952.520132 $46603.8000 $15.7800
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Total 607 3006.759996 $49215.5900 $16.3700
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Number of Children (Unduplicated) With at Least One Authorization 230