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: 10-01-22 and 12-31-22 Date of Report: 01-23-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 3068 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 68 70 123.823807 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.377778 $14.0500 $37.2000
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Subtotal (Total Children Is Unduplicated) 69 71 124.201585 $14.0500 $0.1100
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 16 17 12.711416 $616.5000 $48.5000
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 1.000000 $50.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 4 4 3.016667 $150.8400 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 2 4.000000 $300.0000 $75.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 9 9 16.285714 $1221.4300 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 10 10 18.285714 $1371.4300 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 16 16 32.000000 $1776.0000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 17 18 35.000000 $2625.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 5 6 12.000000 $900.0000 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.4100 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 3.571429 $189.0300 $52.9300
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Subtotal (Total Children Is Unduplicated) 59 88 142.870940 $9465.4600 $66.2500
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.000000 $50.0000 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $231.6200 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 259 287 310.140540 $15507.0300 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 15 19 3.061648 $153.0700 $49.9900
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 36 36 31.115004 $777.8800 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 115 123 219.485712 $10974.2800 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 13 15 23.955556 $1197.7800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 7 7 9.042857 $226.0700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 31 31 60.939681 $3046.9800 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 7 8 11.666666 $583.3300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 3 5.083334 $127.0900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 43 47 67.607687 $3380.3900 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 7 7 10.333333 $516.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 80 88 247.488090 $12374.3800 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 9 10 11.772222 $588.6100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 7.500000 $187.5000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 26 27 170.390476 $8519.5300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 24 27 144.380954 $7219.0500 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 4 5 24.142857 $1207.1500 $50.0000
INTR -T1013 INTERPRETER 122 145 319.750002 $15987.5100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 777 994 5639.641286 $56396.3900 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 11.428571 $822.4000 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 6 6 12.904762 $928.6200 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 2 24.571429 $1768.1600 $71.9600
TRAV -TRAVS Travel by mile 796 1016 5712.986524 $2542.2800 $0.4500
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Subtotal (Total Children Is Unduplicated) 916 2909 13081.389191 $145313.7100 $11.1100
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Total 3068 13348.461716 $154793.2200 $11.6000
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Number of Children (Unduplicated) With at Least One Authorization 998