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: 07-01-22 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 5573 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 54 74 53.557993 $2597.5700 $48.5000
EXIT -EXIT EXIT ASSESSMENT 69 70 85.562755 $4278.1300 $50.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 3 3 4.005479 $300.4100 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 4 4 6.005479 $333.3100 $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 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 4.000000 $300.0000 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 2 9.700000 $485.0000 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 1 2 1.905555 $97.9600 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.016667 $52.2700 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 1 2 2.000000 $102.8200 $51.4100
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Subtotal (Total Children Is Unduplicated) 127 166 179.753928 $9330.4700 $51.9100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 3 2.271308 $11356.5000 $4999.9800
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 4.398630 $219.9300 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 96 112 178.150983 $8907.5600 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 9 10 14.016667 $700.8400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 3 3 13.050000 $326.2500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 420 683 2898.493225 $144924.7200 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 4 4 10.066666 $503.3300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 199 300 1282.493874 $64124.7300 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 3 3 4.133334 $206.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 4 17.633333 $440.8300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 46 64 295.111907 $14755.6100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 379 560 2283.888466 $114194.4800 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 5 6 17.900001 $895.0100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 6 9 35.000001 $875.0000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 9 12 202.933333 $10146.6700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 2 2 33.785714 $1689.2900 $50.0000
INTR -T1013 INTERPRETER 52 107 418.390376 $20919.5100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 566 1553 14926.854530 $179122.2700 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 74.857143 $5386.7200 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 3 4 154.857143 $11143.5200 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 3 77.714286 $5592.3200 $71.9600
TRAV -TRAVS Travel by mile 733 1961 794087.231412 $353368.8200 $0.4500
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Subtotal (Total Children Is Unduplicated) 776 5407 817033.232332 $949800.5800 $1.1600
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Total 5573 817212.986260 $959131.0500 $1.1700
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Number of Children (Unduplicated) With at Least One Authorization 784