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: 10-01-25 and 12-31-25 Date of Report: 01-07-26 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 467 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 6 6 14.173811 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 6 6 14.173811 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 7 7 7.000000 $339.5000 $48.5000
EXIT -EXIT COS Exit 10 10 7.974962 $398.7500 $50.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $161.9600 $80.9800
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 2 2 4.000000 $239.6800 $59.9200
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Subtotal (Total Children Is Unduplicated) 19 21 22.974962 $1301.8500 $56.6600
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 37 38 51.764341 $2588.2200 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 10 10 12.500000 $625.0000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 136 145 247.161908 $12358.1100 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 2 2 2.766667 $138.3400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 63 65 111.633335 $5581.6800 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 1 1 0.750000 $37.5000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 5.133334 $128.3400 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 13 13 15.366668 $768.3400 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 1 1 2.766667 $138.3400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 7 7 8.900001 $222.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 112 112 176.853176 $8842.6700 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 1 1 2.766667 $138.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 4.633334 $115.8400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 3 3 -5.857143 $-316.2800 $54.0000
INTR -T1013 INTERPRETER 20 30 56.500000 $2825.0000 $50.0000
TRAV -TRAVS Travel by mile 4 8 480.000000 $213.6000 $0.4500
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Subtotal (Total Children Is Unduplicated) 184 440 1173.638955 $34405.5000 $29.3200
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Total 467 1210.787728 $35707.3500 $29.4900
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Number of Children (Unduplicated) With at Least One Authorization 197