Summary Report for FSPSAs Initiated During the Report Period Center: 05
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: 04-01-20 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 1330 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 9 9 9.811113 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 9 9 9.811113 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 2 2.000000 $97.0000 $48.5000
EXIT -EXIT EXIT ASSESSMENT 3 3 6.000000 $300.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 4 4 6.000000 $450.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 8 8 13.005479 $975.4100 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 3 3 3.011111 $225.8300 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 1.000000 $75.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 4 4 4.015221 $301.1400 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 6 6 1.013700 $76.0100 $74.9900
IPDEF -T1024TLTSGT F/U PHYC AND DEV EVAL BY EI PROF 1 1 1.000000 $75.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 35 36 60.453424 $3355.1600 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 10 10 13.013698 $722.2600 $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 23 23 11.069867 $830.2300 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 23 23 28.532878 $1583.5700 $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 6 6 6.021918 $451.6500 $75.0000
OCTH -97167 OT EVAL HIGH COMPLEXITY 18 18 7.857840 $401.1400 $51.0500
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 0.194444 $9.9200 $51.0400
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 1 1 0.138889 $7.0900 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.0500 $51.0500
PSTF -97164TL PT RE-EVAL EST PLAN CARE 1 1 0.005556 $0.2900 $51.4600
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 5 5 2.933333 $149.7400 $51.0500
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 0.344444 $17.5800 $51.0400
PSTH -97163 PT EVAL HIGH COMPLEXITY 26 26 20.444510 $1043.6900 $51.0500
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 0.084932 $4.3300 $51.0300
PSTH -97163TLGT PT EVAL HIGH COMPLEXITY 2 3 0.475037 $24.2500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 32 33 28.237585 $1441.5300 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 1.522222 $77.7100 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 1.000000 $51.0500 $51.0500
SPCH -92524TLGT BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 0.188889 $9.6400 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 9 9 7.101370 $316.3700 $44.5500
SPCH -92610TLGT EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $44.5500 $44.5500
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Subtotal (Total Children Is Unduplicated) 163 269 274.688267 $16371.5800 $59.6000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 5 3.284932 $16424.5000 $4999.9500
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 7 7 5.005480 $250.2700 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 13 14 11.321102 $566.0600 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 151 156 263.054763 $13152.7400 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 22 25 17.912700 $895.6400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 51 53 57.446032 $2872.3100 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 12 13 11.166666 $558.3300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 10.714286 $267.8600 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 71 73 59.944441 $2997.2100 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 13 14 11.033332 $551.6600 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.016667 $0.4200 $25.0500
CONSF -CONSF CONSULT, SLP, FACE TO FACE 108 111 113.590479 $5679.5400 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 23 23 28.847619 $1442.3800 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 187 196 1101.128576 $55056.4000 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 92 99 701.647617 $35082.4100 $50.0000
INTR -T1013 INTERPRETER 2 2 13.000000 $650.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 37 40 167.049205 $11933.9900 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 15 17 107.851586 $7704.9200 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 2 2 11.714286 $670.0500 $57.2000
OCCT -97530TLGT OT SESSION BY LICENSED OT 9 10 49.428571 $3531.1700 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 31 33 183.380955 $13100.7500 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 9 10 45.816667 $3273.1500 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 14.714286 $841.0700 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 1 1 11.571429 $661.4200 $57.1600
PHY -97110TL PT SESSION BY LICENSED PT 2 2 7.233333 $516.7500 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 7 9 61.285714 $4378.2600 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 60 61 324.627777 $23191.4100 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 22 22 139.753966 $9984.0300 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 5.428572 $310.5200 $57.2000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 1.642857 $117.3700 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 12 12 76.642858 $5475.3600 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 9 9 48.642857 $675.1600 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 24 26 99.436901 $3679.1700 $37.0000
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Subtotal (Total Children Is Unduplicated) 279 1052 3765.336512 $226492.2500 $60.1500
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Total 1330 4049.835892 $242863.8300 $59.9700
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Number of Children (Unduplicated) With at Least One Authorization 327