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: 10-01-22 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 1266 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 16 16 10.801979 $523.9000 $48.5000
EXIT -EXIT EXIT ASSESSMENT 15 15 16.002740 $800.1400 $50.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 4.000000 $222.0000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 4.000000 $222.0000 $55.5000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 2.533333 $126.6700 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.088889 $4.5700 $51.4200
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.483333 $24.8500 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.4100 $51.4100
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Subtotal (Total Children Is Unduplicated) 37 41 42.910274 $2275.5300 $53.0300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 0.927777 $4638.5000 $4999.5900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 26 27 35.477487 $1773.8800 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 2 2 3.500000 $175.0000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 144 153 265.509525 $13275.4900 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 2 2 2.633333 $131.6700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 67 68 120.071430 $6003.5800 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 1 1 2.000000 $100.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.800000 $45.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 14 14 19.449999 $972.5000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 133 134 224.504764 $11225.2500 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 2 2 2.666667 $133.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 2.533333 $63.3300 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 8 8 55.285715 $2764.2900 $50.0000
INTR -T1013 INTERPRETER 19 31 75.969765 $3798.4900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 169 356 1509.119767 $15091.2000 $10.0000
PHY -97110 PT SESSION BY LICENSED PT 1 1 24.857143 $1788.7200 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 1.142857 $82.2400 $71.9600
TRAV -TRAVS Travel by mile 183 421 81429.197852 $36235.9900 $0.4500
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Subtotal (Total Children Is Unduplicated) 202 1225 83776.647414 $98298.4300 $1.1700
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Total 1266 83819.557688 $100573.9600 $1.2000
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Number of Children (Unduplicated) With at Least One Authorization 212