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: 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 5747 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 2 2 12.052381 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 12.052381 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 51 69 48.029377 $2329.4300 $48.5000
EXIT -EXIT EXIT ASSESSMENT 61 62 79.233988 $3961.6900 $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 1 6.100000 $305.0000 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 1.972222 $101.3900 $51.4100
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 1 1 23.285714 $1197.1200 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.016667 $52.2700 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $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) 116 154 188.648926 $9817.8500 $52.0400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 4 3.499999 $17499.5000 $4999.8600
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.498630 $24.9300 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 100 120 223.393840 $11169.7000 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 8 9 13.016667 $650.8400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 3 3 13.050000 $326.2500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 429 665 2856.281322 $142814.1200 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 3 3 7.900000 $395.0000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 2.000000 $50.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 226 315 1307.218679 $65360.9400 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 4 4 12.333333 $616.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 5 23.066667 $576.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 46 56 257.878576 $12893.9500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 405 562 2277.551159 $113877.5900 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 2 2 8.100000 $405.0000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 5 23.266668 $581.6700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 13 16 222.504762 $11125.2400 $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 50 105 349.890375 $17494.5200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 529 1608 14990.075928 $179880.9500 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 4 5 101.571428 $7309.0900 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 4 5 132.857142 $9560.4000 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 5 81.142857 $5839.0400 $71.9600
TRAV -TRAVS Travel by mile 660 2089 827216.870698 $368111.5100 $0.4500
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Subtotal (Total Children Is Unduplicated) 690 5591 850140.968730 $967413.5600 $1.1400
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Total 5747 850341.670037 $977231.4100 $1.1500
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Number of Children (Unduplicated) With at Least One Authorization 706