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: 01-01-22 and 03-31-22 Date of Report: 04-16-22 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 2716 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
CASE -CASE NON-TCM CASE MANAGEMENT 3 3 4.533333 $167.7300 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 52 53 106.676980 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 55 56 111.210313 $167.7300 $1.5100
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 21 21 28.620156 $1388.0700 $48.5000
EXIT -EXIT EXIT ASSESSMENT 26 26 52.000000 $2600.0000 $50.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 5 5 10.000000 $750.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 5 5 10.000000 $555.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 7 8 16.000000 $1200.0000 $75.0000
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Subtotal (Total Children Is Unduplicated) 58 69 124.620156 $7093.0700 $56.9200
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 231 255 287.932355 $14396.6200 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 10 16 1.557535 $77.8700 $49.9900
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 29 30 26.862623 $671.5600 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 103 120 230.852384 $11542.6400 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 8 8 15.844445 $792.2300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 0.266667 $6.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 35 35 63.511902 $3175.5900 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 3 3 6.744445 $337.2300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 43 46 90.661902 $4533.0900 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 3 3 6.233334 $311.6700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 2.466666 $61.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 73 80 142.278572 $7113.9400 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 8 8 8.744446 $437.2300 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 1.000000 $50.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 6 8 43.714287 $2185.7200 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 4.285714 $214.2900 $50.0000
INTR -T1013 INTERPRETER 98 110 321.102379 $16055.1200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 683 928 5327.920427 $53279.1600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 9.571429 $683.7800 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 3 17.428571 $1245.1000 $71.4400
TRAV -TRAVS Travel by mile 691 930 5271.172810 $2345.6700 $0.4400
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Subtotal (Total Children Is Unduplicated) 801 2591 11881.152893 $119746.7900 $10.0800
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Total 2716 12116.983362 $127007.6000 $10.4800
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Number of Children (Unduplicated) With at Least One Authorization 849