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: 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 1410 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 22 22 26.246032 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 22 22 26.246032 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 8 8 13.106849 $983.0100 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 9 9 14.500000 $1087.5000 $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 1 1 2.000000 $150.0000 $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 40 40 72.175342 $5413.1600 $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 31 31 60.500000 $4537.5000 $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 58 59 115.000000 $6382.5000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 63 64 113.675342 $6308.9800 $55.5000
OCTH -97165 OT EVAL LOW COMPLEXITY 8 8 5.724505 $294.3000 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 4 4 2.794445 $143.6700 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 13 13 4.808371 $247.2000 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 0.255556 $13.1400 $51.4200
PSTH -97161 PT EVAL LOW COMPLEXITY 10 14 11.827778 $608.0700 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 3 3 2.061111 $105.9600 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.4100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 9 11 3.313927 $170.3700 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.4100 $51.4100
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 196 388 639.413393 $41967.0600 $65.6300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 8 9 8.139726 $40698.5000 $4999.9800
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 26 27 20.927779 $1046.4000 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 14 16 11.488888 $574.4400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 6 6 6.000000 $150.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 168 173 164.516666 $8225.8300 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 50 53 59.920634 $2996.0300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 0.011111 $0.2800 $24.9800
CONOF -CONOF CONSULT, OT, FACE TO FACE 66 68 60.406350 $3020.3200 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 45 45 38.950794 $1947.5400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 58 68 47.720629 $2386.0100 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 27 36 19.733329 $986.6500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 92 98 73.226978 $3661.3200 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 50 56 59.230953 $2961.5500 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 1.533333 $38.3300 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 16.142857 $807.1500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 189 207 1049.458719 $52473.0000 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 34 36 207.319042 $10365.9700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2 3 3.000000 $30.0000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 25 26 133.785713 $9627.2300 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 2 3 14.961904 $1076.6600 $71.9600
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 9.714286 $699.0400 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 16 22 79.352380 $5710.2200 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 5 6 18.642856 $1341.5500 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 1 1 5.571429 $400.9200 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 2 2 5.638096 $405.7200 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 19 24 119.173013 $8575.7100 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 4 5 29.285715 $2107.4000 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 1.000000 $71.9600 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 2.285714 $164.4800 $71.9600
TRAV -TRAVS Travel by mile 2 3 50.000000 $22.2500 $0.4500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 269 1000 2317.138894 $162572.4200 $70.1600
-------------------------------------------------------------------------------------------------------------------------------------
Total 1410 2982.798319 $204539.4800 $68.5700
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 339