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: 01-01-23 and 03-31-23 Date of Report: 04-20-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 3135 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 59 61 56.446825 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 59 61 56.446825 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 21 23 27.352577 $1326.6000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 1.082192 $60.7100 $56.1000
EXIT -EXIT EXIT ASSESSMENT 30 32 41.791194 $2089.5700 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 3 6.000000 $450.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 4.000000 $222.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 8 8 16.000000 $1200.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 10 10 20.000000 $1500.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 15 15 29.000000 $1609.5000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 6 7 13.000000 $975.0000 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
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Subtotal (Total Children Is Unduplicated) 79 110 172.225963 $10436.1900 $60.6000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 2.721918 $13609.5000 $4999.9700
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $231.6200 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 288 324 338.964484 $16948.2300 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 11 13 1.538358 $76.9000 $49.9900
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 50 52 45.420484 $1135.5100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 115 123 220.650004 $11032.5200 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 14 14 24.283334 $1214.1700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 5 6 6.000001 $150.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 34 37 66.580952 $3329.0500 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 3 3 4.366667 $218.3400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 1.433333 $35.8300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 49 52 96.283334 $4814.1700 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 8 8 12.400000 $620.0000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.066667 $51.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 79 85 140.688896 $7034.4800 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 7 7 8.833333 $441.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 5.200001 $130.0000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 25 25 152.171428 $7608.5800 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 25 26 193.000001 $9649.9900 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 2 2 13.000000 $650.0000 $50.0000
INTR -T1013 INTERPRETER 150 186 380.971429 $19048.5700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 765 981 5970.500020 $59705.0100 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 10.857143 $781.2800 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 5 5 30.076191 $2164.2800 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 5 5 33.823809 $2433.9700 $71.9600
TRAV -TRAVS Travel by mile 776 997 6001.019068 $2670.4600 $0.4500
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Subtotal (Total Children Is Unduplicated) 942 2964 13763.850855 $165785.7800 $12.0500
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Total 3135 13992.523643 $176221.9700 $12.5900
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Number of Children (Unduplicated) With at Least One Authorization 1012