Summary Report for FSPSAs Ending During the Report Period Center: 02
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: 04-01-23 and 06-30-23 Date of Report: 07-25-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1450 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 19 19 9.461338 $458.8800 $48.5000
EXIT -EXIT EXIT ASSESSMENT 19 19 25.712264 $1285.6200 $50.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 2 2 2.005479 $150.4100 $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 1 1 0.005479 $0.3100 $55.7000
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 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $150.0000 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 0.566667 $28.3400 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.383333 $19.7100 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.033333 $1.7100 $51.3600
SPCH -92521 EVAL OF SPEECH FLUENCY 1 2 2.000000 $102.8200 $51.4100
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Subtotal (Total Children Is Unduplicated) 42 50 48.167893 $2608.7800 $54.1600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 0.077778 $389.0000 $5001.4100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 30 32 37.704251 $1885.2200 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 2 2 3.000000 $150.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 0.750000 $18.7500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 145 160 231.385712 $11569.2700 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 1 1 0.700000 $35.0000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 78 81 113.557143 $5677.8600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.066667 $26.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 13 13 16.733333 $836.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 137 143 197.566667 $9878.3400 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 1 1 2.433333 $121.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.433333 $10.8300 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 6 6 36.857142 $1842.8600 $50.0000
INTR -T1013 INTERPRETER 13 20 28.343704 $1417.1800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 200 399 1298.725326 $15584.6900 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 12.857143 $925.2000 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 3 3 14.571429 $1048.5600 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 3 34.571429 $2487.7600 $71.9600
TRAV -TRAVS Travel by mile 261 529 74691.501760 $33237.7200 $0.4500
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Subtotal (Total Children Is Unduplicated) 287 1400 76722.836150 $87143.2200 $1.1400
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Total 1450 76771.004043 $89752.0000 $1.1700
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Number of Children (Unduplicated) With at Least One Authorization 292