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: 10-01-21 and 12-31-21 Date of Report: 02-04-22 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1314 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 18 18 20.616667 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 18 18 20.616667 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 4 4 8.000000 $600.0000 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 2 2 0.022222 $1.6700 $74.9300
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 3.000000 $225.0000 $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 6 6 4.172907 $312.9600 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 29 30 60.051958 $3332.8800 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 2 2 2.147945 $119.2100 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 20 21 41.000000 $3075.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 46 47 66.601568 $4995.0900 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 15 15 29.000000 $2175.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 4 4 7.000000 $525.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 8 9 14.000000 $1050.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 54 54 85.839923 $6437.9800 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 33 34 64.642857 $3587.6800 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 61 61 98.279453 $5454.5000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 2.002740 $150.2000 $75.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 1 1 0.716667 $35.8400 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 4 4 1.066667 $54.4600 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 22 22 17.808371 $909.1100 $51.0500
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 0.500000 $25.5300 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 5 5 0.761111 $38.8500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 22 22 15.099163 $770.8100 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 1.388889 $70.9000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 26 26 12.345054 $630.2100 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 0.260807 $13.3100 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 2.000000 $89.1000 $44.5500
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Subtotal (Total Children Is Unduplicated) 232 386 546.708302 $35331.3400 $64.6300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 5 3.142466 $15712.0000 $4999.8900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 19 22 21.933333 $1096.6700 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 10 11 8.000000 $400.0000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 160 172 207.253570 $10362.6600 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 31 31 45.324603 $2266.2300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 65 68 81.234127 $4061.7000 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 12 12 20.903176 $1045.1700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 61 63 65.632935 $3281.6400 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 16 17 19.666665 $983.3300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.033333 $25.8300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 124 132 140.085687 $7004.2900 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 37 39 47.666662 $2383.3100 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 168 180 1048.509525 $52425.4900 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 23 23 135.885715 $6794.2800 $50.0000
INTR -T1013 INTERPRETER 2 2 4.000000 $200.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 37 38 219.785715 $15701.4900 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 5.857143 $418.4300 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 32 34 180.033332 $12861.5800 $71.4400
PHY -97110HM PT SESSION BY PT ASST 3 3 12.428571 $710.4200 $57.1600
PHY -97110TL PT SESSION BY LICENSED PT 1 1 3.428571 $244.9400 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 1 1 4.142857 $295.9700 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 47 49 246.504766 $17610.2900 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 18.433333 $1316.8800 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 2 2 11.747619 $839.2500 $71.4400
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Subtotal (Total Children Is Unduplicated) 245 910 2552.633704 $158041.8100 $61.9100
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Total 1314 3119.958673 $193373.1500 $61.9800
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Number of Children (Unduplicated) With at Least One Authorization 395