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: 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 1596 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 21 21 10.664916 $517.2500 $48.5000
EXIT -EXIT EXIT ASSESSMENT 18 18 17.569407 $878.4700 $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
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
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Subtotal (Total Children Is Unduplicated) 40 48 40.245281 $2210.2600 $54.9200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 1.494444 $7472.0000 $4999.8500
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 29 31 40.200679 $2010.0400 $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 151 170 292.183332 $14609.1600 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 1 1 1.266667 $63.3400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 2.000000 $50.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 87 88 146.220630 $7311.0100 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 1 1 1.033333 $51.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.966667 $49.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 12 12 21.533334 $1076.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 146 151 258.181745 $12909.0900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 4.966667 $124.1700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 6 6 31.714286 $1585.7200 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 2 2 16.000000 $800.0000 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 1.000000 $50.0000 $50.0000
INTR -T1013 INTERPRETER 10 19 43.057988 $2152.9100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 184 444 1737.332449 $20848.0000 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 3.428571 $246.7200 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 2 2 5.714285 $411.2000 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 2 3.428571 $246.7200 $71.9600
TRAV -TRAVS Travel by mile 230 607 102812.749399 $45751.6800 $0.4500
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Subtotal (Total Children Is Unduplicated) 238 1548 105429.223047 $117987.9800 $1.1200
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Total 1596 105469.468328 $120198.2400 $1.1400
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Number of Children (Unduplicated) With at Least One Authorization 249