Summary Report for FSPSAs Ending During the Report Period Center: 05
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: 04-01-20 and 06-30-20 Date of Report: 07-20-20 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1615 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 14 14 29.104764 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 14 14 29.104764 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 9 10 15.200000 $760.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 3 3 5.000000 $375.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 10 10 16.005479 $1200.4100 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 3 3 3.011111 $225.8300 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 4 4 8.000000 $600.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 5 5 5.015221 $376.1400 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 6 6 2.013700 $151.0100 $74.9900
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 26 28 46.087671 $2557.8700 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 6 6 6.013698 $333.7600 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 10 10 16.002740 $1200.2000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 8 8 8.510960 $638.3200 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 5 5 7.002740 $525.2000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 2 2 2.002740 $150.2000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 22 22 9.069867 $680.2300 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 24 24 28.563015 $1585.2400 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 7 7 11.502740 $638.4000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 8 8 6.479452 $485.9600 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 11 11 5.025267 $256.5400 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 35 35 18.811874 $960.3500 $51.0500
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 2 2 0.538889 $27.5100 $51.0500
PSTF -97164TL PT RE-EVAL EST PLAN CARE 1 1 0.005556 $0.2900 $51.4600
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 4 4 3.211111 $163.9300 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 27 28 16.470397 $840.8200 $51.0500
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 0.084932 $4.3300 $51.0300
PSTH -97163TLGT PT EVAL HIGH COMPLEXITY 1 1 0.083333 $4.2500 $51.0300
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 0.022222 $1.1300 $51.0000
SPCH -92522 EVAL OF SPCH SOUND PROD 6 6 4.294444 $219.2300 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 71 72 50.377313 $2571.7600 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 4 4 3.188889 $162.7900 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 12 12 10.508067 $468.1400 $44.5500
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Subtotal (Total Children Is Unduplicated) 224 343 313.103428 $18468.0100 $58.9800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 7 7 6.283333 $31416.5000 $4999.9700
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 15 15 78.691194 $3934.5600 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 12 13 9.287769 $464.3900 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 201 218 208.078567 $10403.9100 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 15 17 19.538888 $976.9400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.466667 $36.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 68 70 62.546429 $3127.3200 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 4 4 4.661111 $233.0600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.100000 $52.5000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 85 90 136.794838 $6839.7200 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 5 5 5.716666 $285.8300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.016667 $0.4200 $25.0500
CONSF -CONSF CONSULT, SLP, FACE TO FACE 165 179 166.045241 $8302.2800 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 7 7 6.727777 $336.3900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.533333 $13.3300 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 6 7 31.142856 $778.5700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 216 232 1304.199991 $65210.0500 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 67 74 466.428570 $23321.4400 $50.0000
INTR -T1013 INTERPRETER 6 6 34.285714 $1714.2900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1 1 1.466667 $14.6700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 48 50 230.640476 $16476.9500 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 18 20 88.289682 $6307.4200 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 2 2 11.342857 $648.8100 $57.2000
OCCT -97530TLGT OT SESSION BY LICENSED OT 2 2 6.571429 $469.4600 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 48 49 272.147616 $19442.2500 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 9 9 34.428570 $2459.5900 $71.4400
PHY -97110HM PT SESSION BY PT ASST 10 10 65.785713 $3760.3200 $57.1600
PHY -97110TLGT PT SESSION BY LICENSED PT 3 3 9.857143 $704.2000 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 96 101 533.357138 $38103.0600 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 19 20 108.857140 $7776.7800 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 8 8 41.571428 $2969.8600 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 12 12 78.428570 $1088.5900 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 23 23 57.508333 $2127.8000 $37.0000
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Subtotal (Total Children Is Unduplicated) 311 1258 4084.798373 $259797.8800 $63.6000
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Total 1615 4427.006565 $278265.8900 $62.8600
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Number of Children (Unduplicated) With at Least One Authorization 395