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: 10-01-21 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 1115 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 7 7 9.757142 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 7 7 9.757142 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 2.283333 $171.2500 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 2 2 0.022222 $1.6700 $74.9300
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 4 4 2.024962 $151.8700 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 13 13 16.334932 $906.5900 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 2 2 2.082192 $115.5600 $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 47 48 66.683760 $5001.2600 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 16 16 31.000000 $2325.0000 $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 8 13.000000 $975.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 57 57 89.716636 $6728.7300 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 34 35 65.642857 $3643.1800 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 61 61 98.112330 $5445.2200 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 2.002740 $150.2000 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 3 3 0.861112 $43.9600 $51.0600
OCTH -97167 OT EVAL HIGH COMPLEXITY 20 20 14.772679 $754.1500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 1.372222 $70.0500 $51.0500
PSTH -97162TLGT PT EVAL MODERATE COMPLEXITY 1 1 0.127778 $6.5200 $51.0600
PSTH -97163 PT EVAL HIGH COMPLEXITY 12 12 4.164689 $212.6100 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 3 3 3.000000 $153.1500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 19 19 10.834628 $553.1100 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 1.000000 $51.0500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 1.716666 $76.4700 $44.5500
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Subtotal (Total Children Is Unduplicated) 162 342 479.755738 $31487.6500 $65.6300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.000000 $15000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 21 25 24.644445 $1232.2300 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 11 13 7.527777 $376.3900 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 159 166 201.864681 $10093.2200 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 16 16 19.446032 $972.3000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 74 75 94.720638 $4736.0500 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 4 4 3.755555 $187.7800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 46 47 56.641274 $2832.0900 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 8 8 10.655556 $532.7800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 122 124 136.255163 $6812.7800 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 23 24 31.512699 $1575.6400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 165 170 1076.028562 $53801.4800 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 7 7 34.414287 $1720.7100 $50.0000
INTR -T1013 INTERPRETER 2 2 4.000000 $200.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 30 30 209.852383 $14991.8600 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 21 21 143.785713 $10272.0400 $71.4400
PHY -97110TL PT SESSION BY LICENSED PT 1 1 1.466667 $104.7800 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 26 26 170.670237 $12192.6800 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 2 2 10.442857 $746.0400 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 2 2 14.000000 $194.3200 $13.8800
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Subtotal (Total Children Is Unduplicated) 243 766 2254.684526 $138575.1500 $61.4600
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Total 1115 2744.197406 $170062.8000 $61.9700
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Number of Children (Unduplicated) With at Least One Authorization 298