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: 01-01-23 and 03-31-23 Date of Report: 04-20-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1391 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 32 34 52.298414 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 32 34 52.298414 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 6 7 13.000000 $975.0000 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 8 8 12.500000 $937.5000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 6 6 10.011111 $750.8300 $75.0000
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 5 5 8.000000 $600.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 12 12 21.000000 $1165.5000 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 10 10 14.159056 $785.8200 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 11 11 22.000000 $1650.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 39 39 72.010958 $5400.8300 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 6 6 10.500000 $787.5000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 29 29 56.500000 $4237.5000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 24 24 44.000000 $3300.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 40 40 77.000000 $5775.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 59 60 117.000000 $6493.5000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 63 64 115.510958 $6410.8600 $55.5000
OCTH -97165 OT EVAL LOW COMPLEXITY 8 8 3.095510 $159.1300 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.005556 $0.2900 $51.8200
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 0.461111 $23.7100 $51.4100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 18 18 7.082268 $364.1000 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 2 2 1.200000 $61.6900 $51.4100
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 5 6 5.105556 $262.4800 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 11 12 7.774277 $399.6800 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 2 2 1.161644 $59.7200 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 4 4 2.279223 $117.1700 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.4100 $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 19 20 7.711036 $396.4200 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.272222 $65.4000 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $44.8600 $44.8600
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 6.571429 $347.8200 $52.9300
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Subtotal (Total Children Is Unduplicated) 234 411 654.911915 $42682.1900 $65.1700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 1.131507 $5657.5000 $4999.9700
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 23 24 31.961905 $1598.1000 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 13 16 24.328571 $1216.4300 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 6 6 6.000000 $150.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 153 162 177.022220 $8851.1000 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 41 43 48.609522 $2430.4700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 0.011111 $0.2800 $24.9800
CONOF -CONOF CONSULT, OT, FACE TO FACE 62 64 77.875396 $3893.7700 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 31 33 42.116667 $2105.8400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.988889 $24.7200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 56 65 58.934133 $2946.7400 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 32 39 32.348414 $1617.4300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 109 118 129.316273 $6465.8300 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 43 44 60.257143 $3012.8600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 1.900000 $47.5000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 3 18.285714 $914.2900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 165 184 1072.923587 $53646.1900 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 33 34 210.571427 $10528.5800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3 4 15.428571 $154.2900 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 19 20 119.171429 $8575.5700 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 2.500000 $179.9000 $71.9600
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 4.714286 $339.2400 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 22 26 141.328572 $10170.0100 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 5 5 32.285713 $2323.2900 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 1 1 1.100000 $79.1600 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 1 1 8.428571 $606.5200 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 32 38 185.029365 $13314.7000 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 14.428571 $1038.2800 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 2 2 13.428571 $966.3200 $71.9600
TRAV -TRAVS Travel by mile 3 4 62.428571 $27.7800 $0.4400
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Subtotal (Total Children Is Unduplicated) 248 946 2594.854699 $142882.6500 $55.0600
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Total 1391 3302.065028 $185564.8400 $56.2000
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Number of Children (Unduplicated) With at Least One Authorization 404