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: 10-01-22 and 12-31-22 Date of Report: 01-23-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1100 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 24 24 20.311108 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 24 24 20.311108 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 1 1 2.000000 $100.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 3 3 4.205556 $315.4200 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 7 7 13.000000 $975.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024TLTSGT F/U PHYC AND DEV EVAL BY EI PROF 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 9 9 12.167123 $675.2700 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 5 5 8.000000 $444.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 12 13 26.000000 $1950.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 42 42 67.088737 $5031.6500 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 6 6 9.500000 $712.5000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 15 15 26.005479 $1950.4100 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 13 13 25.000000 $1875.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 52 52 77.043833 $5778.2900 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 40 40 76.566667 $4249.4500 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 63 63 92.098628 $5111.4800 $55.5000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 3 3 6.000000 $450.0000 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 1.000000 $50.0000 $50.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 0.266667 $13.7100 $51.4200
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 0.083333 $4.2800 $51.3900
OCTH -97167 OT EVAL HIGH COMPLEXITY 12 12 5.500914 $282.8000 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 0.156164 $8.0300 $51.4200
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
PSTH -97161TL PT EVAL LOW COMPLEXITY 1 1 0.122222 $6.2800 $51.4000
PSTH -97163 PT EVAL HIGH COMPLEXITY 6 6 3.611110 $185.6400 $51.4100
PSTH -97163TLGT PT EVAL HIGH COMPLEXITY 1 1 0.022222 $1.1400 $51.3600
SPCH -92521 EVAL OF SPEECH FLUENCY 4 4 2.227778 $114.5300 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 15 16 5.605327 $288.1700 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.4100 $51.4100
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 1.000000 $51.4100 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 1.073973 $48.1800 $44.8600
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $44.8600 $44.8600
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Subtotal (Total Children Is Unduplicated) 185 331 483.345733 $31921.7500 $66.0400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 17 22 13.283332 $664.1600 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 14 15 12.061111 $603.0600 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 2.000000 $50.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 143 153 173.449601 $8672.4700 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 43 44 60.885713 $3044.2800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 46 49 52.457146 $2622.8700 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 6 6 7.188889 $359.4500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 43 48 48.784921 $2439.2500 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 14 15 16.166667 $808.3400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.466667 $61.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 100 102 121.493646 $6074.6600 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 38 38 48.159524 $2407.9800 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 19.571429 $978.5700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 159 170 904.315877 $45215.8000 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 22 25 135.757144 $6787.8600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2 2 9.428571 $94.2900 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 13 14 45.357143 $3263.9000 $71.9600
OCCT -97530TL OT SESSION BY LICENSED OT 1 2 11.000000 $791.5600 $71.9600
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 7.285714 $524.2800 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 15 15 98.357142 $7077.7700 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 1 1 0.071429 $5.1400 $71.9300
PHY -97110TLGT PT SESSION BY LICENSED PT 1 1 8.857143 $637.3600 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 13 13 40.142857 $2888.6700 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 0.571429 $41.1200 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 1.571429 $113.0800 $71.9600
TRAV -TRAVS Travel by mile 1 1 45.000000 $20.0300 $0.4500
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Subtotal (Total Children Is Unduplicated) 208 745 1886.684524 $101247.5700 $53.6600
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Total 1100 2390.341365 $133169.3200 $55.7100
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Number of Children (Unduplicated) With at Least One Authorization 362