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: 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 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 6 6 6.955556 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 6 6 6.955556 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 6 6 11.000000 $825.0000 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 3 3 3.005479 $225.4100 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 0.005479 $0.4100 $75.2900
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 6 6 9.005479 $675.4100 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 37 37 56.415526 $3131.0700 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 6 6 6.010959 $333.6000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 20 20 34.000000 $2550.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 47 47 70.065904 $5254.9500 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 11 11 21.000000 $1575.0000 $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 59 60 94.054794 $7054.1100 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 35 37 62.005479 $3441.3100 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 23 23 36.019177 $1999.0700 $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 1 1 0.438889 $22.4100 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 24 24 30.434606 $1553.6900 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 1.033334 $52.7600 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 12 13 5.380823 $274.7000 $51.0500
PSTH -97163TLGT PT EVAL HIGH COMPLEXITY 3 3 0.235769 $12.0400 $51.0600
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 30 30 15.244598 $778.2500 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.0500 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 2.450000 $125.0700 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 2 2 1.094444 $55.8700 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 6 6 3.385161 $150.8100 $44.5500
SPCH -92610GT EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 1.355556 $60.3900 $44.5500
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Subtotal (Total Children Is Unduplicated) 189 361 485.649675 $31777.9900 $65.4300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 6 6.000000 $30000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 18 21 17.185748 $859.3000 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 15 17 14.416667 $720.8400 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 178 187 190.596834 $9529.8900 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 25 26 23.586510 $1179.3400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 45 47 49.414287 $2470.7200 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 7 8 15.311110 $765.5500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 3.428571 $85.7200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 56 58 61.611116 $3080.5800 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 17 17 19.807937 $990.4000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 132 136 147.269845 $7363.5100 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 23 24 26.181747 $1309.1000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 3 1.844444 $46.1100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 198 206 1356.499977 $67825.1100 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 36 38 247.434044 $12371.7200 $50.0000
INTR -T1013 INTERPRETER 1 1 7.428571 $371.4300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 40 41 234.214288 $16732.2600 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 4 4 18.749207 $1339.4400 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 30 33 192.816667 $13774.8200 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 2 2 9.000000 $642.9600 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 12.714286 $726.7500 $57.1600
PHY -97110TL PT SESSION BY LICENSED PT 2 2 13.171429 $940.9600 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 4 4 27.428572 $1959.4900 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 62 63 364.175395 $26016.7200 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 15.300000 $1093.0300 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 2 2 13.000000 $928.7200 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 5 5 27.352381 $1954.0600 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 31.285714 $434.2500 $13.8800
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Subtotal (Total Children Is Unduplicated) 249 963 3147.225347 $205512.7500 $65.3000
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Total 1330 3639.830578 $237290.7300 $65.1900
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Number of Children (Unduplicated) With at Least One Authorization 311