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: 10-01-23 and 12-31-23 Date of Report: 01-14-24 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 3296 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 62 62 53.269841 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 62 62 53.269841 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 16 18 13.608677 $660.0300 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 3 3 2.106849 $118.1900 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 1.000000 $15.8400 $15.8400
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.000000 $21.0400 $21.0400
EXIT -EXIT COS Exit 67 69 49.766440 $2488.3100 $50.0000
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 3 3 6.000000 $450.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 4 4 8.000000 $600.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 3 3 6.000000 $333.0000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 3 3 6.000000 $333.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 5 7 14.000000 $1050.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $150.0000 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.4100 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.4100 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 6.857143 $352.5200 $51.4100
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Subtotal (Total Children Is Unduplicated) 97 119 122.339109 $6888.5700 $56.3100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 6 7.571429 $37857.0000 $4999.9800
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 241 269 300.309363 $15015.4700 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 27 29 19.928085 $996.3900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 26 28 28.522147 $713.0500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 139 152 279.782536 $13989.1100 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 6 6 13.166667 $658.3400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 6 6 4.000000 $100.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 69 71 120.833336 $6041.6800 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 2 2 2.133333 $106.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 4.400000 $110.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 50 51 99.809525 $4990.4900 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 4 4 5.333333 $266.6700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 3 3 1.766666 $44.1700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 68 72 109.079363 $5453.9600 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 7 7 7.466667 $373.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 5 7.866667 $196.6700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 34 35 217.900002 $10895.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 38 38 294.280955 $14714.0400 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 8 9 58.447620 $2922.3800 $50.0000
INTR -T1013 INTERPRETER 120 176 295.838095 $14791.9100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 845 1047 6384.212728 $76610.5500 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 4 5 19.790477 $1424.1200 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 7 7 44.733334 $3219.0100 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 2 2 9.142858 $657.9200 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 8 9 41.604762 $2993.8900 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 1.714286 $123.3600 $71.9600
TRAV -TRAVS Travel by mile 872 1073 6414.684158 $2854.5400 $0.4500
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Subtotal (Total Children Is Unduplicated) 996 3115 14794.318392 $218119.6700 $14.7400
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Total 3296 14969.927342 $225008.2400 $15.0300
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Number of Children (Unduplicated) With at Least One Authorization 1069