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: 10-01-20 and 12-31-20 Date of Report: 01-23-21 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 996 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
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 21 23 24.386116 $1182.7300 $48.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.000000 $13.8700 $13.8700
EVAL -96111GT DEVELOPMENTAL EVALUATION 1 1 1.000000 $50.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 28 28 26.437671 $1321.8800 $50.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 4.500000 $249.7500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.500000 $187.5000 $75.0000
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Subtotal (Total Children Is Unduplicated) 52 57 61.823787 $3155.7300 $51.0400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 3 3.000000 $15000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 41 45 39.325181 $1966.2600 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 2 2 1.406944 $70.3500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 3 4 2.012500 $50.3100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 127 135 231.888457 $11594.4300 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 1.466667 $73.3400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 66 66 113.633335 $5681.6800 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 2 2 2.100000 $105.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 1.800000 $45.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 10 10 11.833334 $591.6700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.300000 $7.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 116 117 188.561903 $9428.0900 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 2 2 2.366667 $118.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.400000 $35.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 5 6 32.228571 $1611.4300 $50.0000
INTR -T1013 INTERPRETER 11 20 73.587865 $3679.4000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 146 270 1192.181658 $11921.8300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 10.857143 $775.6300 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 1 1 10.857143 $775.6300 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 2 17.714286 $1265.5000 $71.4400
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 1 1 1.000000 $37.0000 $37.0000
TRAV -TRAVS Travel by mile 123 247 59215.727996 $26351.0000 $0.4500
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Subtotal (Total Children Is Unduplicated) 174 939 61155.249650 $91184.3700 $1.4900
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Total 996 61217.073437 $94340.1000 $1.5400
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Number of Children (Unduplicated) With at Least One Authorization 195