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: 10-01-20 and 12-31-20 Date of Report: 01-23-21 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1683 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 9.969842 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 9.969842 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 25 29 23.352099 $1132.5800 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $56.4900 $56.4900
EVAL -96111 DEVELOPMENTAL EVALUATION 2 3 1.172223 $58.6200 $50.0000
EXIT -EXIT EXIT ASSESSMENT 28 28 30.089726 $1504.4900 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 6.000000 $450.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 6 8 16.000000 $888.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 60 60 110.027395 $8252.0600 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 28 28 52.487671 $3936.5800 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 1 1 0.005479 $0.4100 $75.2900
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 102 103 189.549311 $10520.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 22 22 41.516437 $3113.7400 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 3 3 0.419026 $21.3900 $51.0500
OCTF -97168GT OT RE-EVAL EST PLAN CARE 1 1 0.161644 $8.2500 $51.0400
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 1.466667 $74.8800 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 7 7 8.798108 $449.1400 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 15 15 16.047118 $819.2100 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 4 4 0.357915 $18.2700 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 0.131507 $6.7100 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 14 14 6.854109 $349.9000 $51.0500
SCREEN-T1023 SCREENING 1 1 1.000000 $50.0000 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 5 5 5.000000 $255.2500 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 25 25 13.411035 $684.6400 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.136986 $6.9900 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 12.069048 $537.6800 $44.5500
SPCH -92610GT EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $44.5500 $44.5500
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Subtotal (Total Children Is Unduplicated) 207 372 541.053504 $33440.8700 $61.8100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 30 34 30.435257 $152176.0000 $4999.9900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 40 44 34.891848 $1744.5900 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 2 2 1.273611 $63.6800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 4 5 2.079167 $51.9800 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 133 140 226.997978 $11349.9200 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 75 79 130.428568 $6521.4200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 3.500000 $87.5000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 16 16 26.166666 $1308.3300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.766667 $44.1700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 117 122 186.652380 $9332.6200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 4.766667 $119.1700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 135 140 792.785711 $39639.2700 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 7.857143 $392.8600 $50.0000
INTR -T1013 INTERPRETER 12 20 40.402151 $2020.1100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 163 281 1087.895954 $10878.9600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 38 39 284.285713 $20309.3600 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 3 3 6.285714 $449.0600 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 3 3 25.285715 $1446.3400 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 29 29 200.418789 $14317.8900 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 5 5 30.142857 $2153.4100 $71.4400
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 1 1 4.285714 $244.9700 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 43 43 277.652379 $19835.4900 $71.4400
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 1 1 1.000000 $37.0000 $37.0000
TRAV -TRAVS Travel by mile 149 295 61801.827990 $27501.8100 $0.4500
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Subtotal (Total Children Is Unduplicated) 208 1309 65209.084639 $322025.9000 $4.9400
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Total 1683 65760.107985 $355466.7600 $5.4100
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Number of Children (Unduplicated) With at Least One Authorization 298