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: 10-01-22 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 1089 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 27 27 36.817459 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 27 27 36.817459 $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 4.128767 $309.6600 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 6 6 11.000000 $825.0000 $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 7 7 10.200000 $566.1000 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 4 4 6.000000 $333.0000 $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 41 41 65.088737 $4881.6500 $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 53 53 79.043833 $5928.2900 $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 61 61 90.038354 $4997.1300 $55.5000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 3 3 6.000000 $450.0000 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 11 11 7.087138 $364.3500 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.005556 $0.2900 $51.8200
OCTH -97167 OT EVAL HIGH COMPLEXITY 10 10 3.650000 $187.6500 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 2 2 1.483333 $76.2600 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 3 3 2.111111 $108.5300 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 8 8 5.283256 $271.6100 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 2 2 1.246575 $64.0900 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 5 5 3.569102 $183.4900 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 4 4 4.000000 $205.6400 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 15 15 4.628158 $237.9400 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.4100 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 8.857143 $468.8100 $52.9300
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Subtotal (Total Children Is Unduplicated) 165 334 489.493209 $32098.2500 $65.5700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.000000 $15000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 20 22 29.341269 $1467.0600 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 15 16 24.596825 $1229.8400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 2.000000 $50.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 140 148 198.032540 $9901.6300 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 38 39 50.392857 $2519.6400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 45 45 64.432542 $3221.6400 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 20 21 23.933333 $1196.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.855556 $21.3900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 39 42 39.123809 $1956.1900 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 16 17 15.222222 $761.1100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 83 87 121.955553 $6097.7700 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 44 44 69.699205 $3484.9600 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 4 4 40.285714 $2014.2900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 155 163 1090.766672 $54538.2900 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 25 27 135.428571 $6771.4200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2 2 5.714286 $57.1400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 12 13 80.783334 $5813.1600 $71.9600
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 3.714286 $267.2800 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 15 15 102.500000 $7375.9000 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 3 3 15.785714 $1135.9400 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 1 1 12.857143 $925.2000 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 10 10 73.750000 $5307.0400 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 10.857143 $781.2800 $71.9600
TRAV -TRAVS Travel by mile 1 1 45.000000 $20.0300 $0.4500
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Subtotal (Total Children Is Unduplicated) 211 728 2260.028574 $131914.8300 $58.3700
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Total 1089 2786.339242 $164013.0800 $58.8600
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Number of Children (Unduplicated) With at Least One Authorization 282