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: 10-01-23 and 12-31-23 Date of Report: 01-14-24 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1208 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 15 15 16.644443 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.011111 $0.4100 $37.1600
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Subtotal (Total Children Is Unduplicated) 16 16 16.655554 $0.4100 $0.0200
Screening, Eval, and Assessment, Class # 02
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 4 4 5.111111 $383.3300 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 6.000000 $450.0000 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 0.022222 $1.6700 $74.9300
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 4 4 6.000000 $450.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 3 3 6.000000 $450.0000 $75.0000
IPDEF -T1024TLTSGT F/U PHYC AND DEV EVAL BY EI PROF 1 1 0.005556 $0.4200 $75.5900
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 12 13 21.022222 $1166.7300 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 5 5 10.000000 $555.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 42 42 80.505479 $6037.9100 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 34 34 67.000000 $5025.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 3 3 6.000000 $450.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 32 32 64.000000 $4800.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 38 38 76.000000 $5700.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 17 17 33.500000 $2512.5000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 47 47 91.505479 $5078.5600 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 53 54 105.500000 $5855.2500 $55.5000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $150.0000 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 8 8 3.196499 $164.3300 $51.4100
OCTH -97165TL OT EVAL LOW COMPLEXITY 1 1 0.394444 $20.2800 $51.4000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 4 4 1.161111 $59.6900 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 5 5 1.294444 $66.5500 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 2 2.000000 $102.8200 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 3 3 0.810655 $41.6800 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 5 5 3.461111 $177.9400 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.377778 $19.4200 $51.4100
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 1 1 0.066667 $3.4300 $51.4300
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 0.550000 $28.2800 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 0.183333 $9.4200 $51.4000
SPCH -92521 EVAL OF SPEECH FLUENCY 5 5 3.257991 $167.4900 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.494444 $25.4200 $51.4100
SPCH -92522GT EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.4100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 7 7 1.655556 $85.1100 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.266667 $13.7100 $51.4200
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 2 10.714286 $550.8200 $51.4100
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Subtotal (Total Children Is Unduplicated) 201 355 616.057055 $41005.5800 $66.5600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 4.000000 $20000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 24 28 24.844444 $1242.2200 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 8 10 10.600000 $530.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 156 164 193.923801 $9696.1500 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 42 45 45.549204 $2277.4500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 63 68 60.162697 $3008.1300 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 41 44 56.708728 $2835.4200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 41 43 46.300396 $2315.0200 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 21 21 23.191665 $1159.5800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 70 74 75.696423 $3784.7800 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 40 42 53.443252 $2672.1400 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 6.933333 $173.3300 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 5 5 29.285715 $1464.2800 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 172 183 955.811111 $47790.5700 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 34 36 180.500001 $9025.0100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 20 21 114.015874 $8204.6100 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 4 4 25.112699 $1807.1200 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 17 18 71.214284 $5124.5900 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 3 3 9.214285 $663.0600 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 1 1 0.857143 $61.6800 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 17 18 78.823812 $5672.1600 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 0.571429 $41.1200 $71.9600
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Subtotal (Total Children Is Unduplicated) 227 837 2067.760296 $129573.3900 $62.6600
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Total 1208 2700.472905 $170579.3700 $63.1700
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Number of Children (Unduplicated) With at Least One Authorization 386