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: 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 1502 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 12 12 12.415873 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 12 12 12.415873 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 3 3 6.000000 $450.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 10 10 18.000000 $1350.0000 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 4 4 5.005479 $375.4100 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.000000 $75.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 2 2 1.005479 $75.4100 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 6 6 9.005479 $675.4100 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TLTSGT F/U PHYC AND DEV EVAL BY EI PROF 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 45 46 71.607534 $3974.2200 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 7 7 7.010959 $389.1000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 22 22 36.090411 $2706.7800 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 46 46 66.074123 $4955.5700 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 10 10 19.000000 $1425.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 9 9 11.002740 $825.2000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 58 59 92.054794 $6904.1100 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 36 38 62.153424 $3449.5100 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 24 24 38.019177 $2110.0700 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 0.005479 $0.4100 $75.2900
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 3 3 6.000000 $450.0000 $75.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 0.355555 $18.1500 $51.0400
OCTH -97167 OT EVAL HIGH COMPLEXITY 22 22 15.913373 $812.3800 $51.0500
OCTH -97167GT OT EVAL HIGH COMPLEXITY 2 2 0.783333 $39.9900 $51.0500
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 0.316667 $16.1700 $51.0600
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.0500 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 7 7 2.872223 $146.6300 $51.0500
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 0.161111 $8.2200 $51.0500
PSTH -97162TLGT PT EVAL MODERATE COMPLEXITY 2 2 0.288889 $14.7500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 25 27 19.367266 $988.7000 $51.0500
PSTH -97163GT PT EVAL HIGH COMPLEXITY 2 2 0.355555 $18.1500 $51.0400
PSTH -97163TLGT PT EVAL HIGH COMPLEXITY 1 1 0.316667 $16.1700 $51.0600
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 47 47 20.762254 $1059.9200 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 1.783333 $91.0400 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 1.394444 $71.1800 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 1 2 2.000000 $102.1000 $51.0500
SPCH -92524TLGT BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 0.327778 $16.7300 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 10 10 8.574581 $381.9900 $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) 246 429 531.608107 $34440.1300 $64.7800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 7 7 5.131507 $25657.5000 $4999.9900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 18 20 16.738128 $836.9100 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 17 19 15.833333 $791.6700 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 166 177 216.759920 $10837.9900 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 26 27 23.519844 $1176.0100 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 53 57 74.142856 $3707.1300 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 10 10 14.996031 $749.8000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 3 5.661904 $141.5500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 75 77 70.011110 $3500.5500 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 21 21 23.641271 $1182.0700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 129 137 154.584916 $7729.2300 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 20 21 25.395236 $1269.7600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 1.566667 $39.1700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 189 200 1196.019048 $59800.9500 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 54 55 273.872147 $13693.6100 $50.0000
INTR -T1013 INTERPRETER 1 1 5.714286 $285.7200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 36 37 260.330952 $18598.0300 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 9 9 39.843650 $2846.4300 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 3 3 15.857143 $907.0300 $57.2000
OCCT -97530TLGT OT SESSION BY LICENSED OT 6 6 39.285715 $2806.5600 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 39 41 223.523810 $15968.5300 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 7 7 27.109525 $1936.7000 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 10.857143 $620.5900 $57.1600
PHY -97110TL PT SESSION BY LICENSED PT 3 3 11.466667 $819.1800 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 6 6 34.428572 $2459.5700 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 68 72 375.912699 $26855.2300 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 12 13 64.935715 $4639.0000 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 10.857143 $621.0300 $57.2000
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 1 1 5.000000 $286.0000 $57.2000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 3 3 27.285714 $1949.2900 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 4 4 18.142857 $1296.1300 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 8 9 68.642856 $952.7600 $13.8800
SPL -92508TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 0.285714 $3.9700 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 8 9 12.857144 $475.7200 $37.0000
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Subtotal (Total Children Is Unduplicated) 254 1061 3370.211223 $215441.3100 $63.9300
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Total 1502 3914.235203 $249881.4400 $63.8400
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Number of Children (Unduplicated) With at Least One Authorization 386