Summary Report for FSPSAs Initiated During the Report Period Center: 55
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: 10-01-20 and 12-31-20 Date of Report: 01-23-21 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1875 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 19 19 481.465078 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 23 23 1656.700000 $61297.9000 $37.0000
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Subtotal (Total Children Is Unduplicated) 42 42 2138.165078 $61297.9000 $28.6700
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.323288 $14.5500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.244444 $28.1100 $114.9800
EVAL -96111 DEVELOPMENTAL EVALUATION 27 29 28.563622 $1428.1800 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 1 2 4.000000 $200.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 41 43 74.142857 $3707.1500 $50.0000
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 7 7 14.000000 $1050.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $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 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 3 3 6.000000 $333.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 16 16 32.000000 $2400.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 204 205 428.000000 $32100.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 24 24 48.000000 $3600.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 77 79 158.000000 $11850.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 11 11 22.000000 $1650.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 38 38 94.000000 $7050.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 30 31 61.000000 $3385.5000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 56 58 116.000000 $6438.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 4.000000 $300.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 36 37 8.561110 $437.0400 $51.0500
OCTF -97168GT OT RE-EVAL EST PLAN CARE 7 7 2.405555 $122.8000 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.161111 $8.2200 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 3 3 12.791270 $653.0000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 45 46 22.594445 $1153.4500 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 21 22 5.988889 $305.7300 $51.0500
PSTF -97164GT PT RE-EVAL EST PLAN CARE 4 5 2.350000 $119.9700 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 21 22 13.127778 $670.1700 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 89 93 40.206349 $2052.5300 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 13 13 5.583333 $285.0300 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.288889 $14.7500 $51.0500
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Subtotal (Total Children Is Unduplicated) 430 806 1216.332940 $82257.1600 $67.6300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 1.450000 $7250.0000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.733333 $36.6700 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.655556 $32.7800 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 1.400000 $322.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 1.000000 $50.0000 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 3 5 4.000000 $200.0000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 99 104 65.222219 $3261.1000 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 2 2 0.822222 $41.1100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 98 101 102.599998 $2565.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 49 87 42.033334 $2101.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 27 46 27.438888 $685.9700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 22 41 23.122224 $1156.1200 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 15 27 34.100002 $852.5100 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 82 84 57.733326 $2886.6300 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 0.172222 $8.6100 $49.9900
CONSP -CONSP CONSULT, SLP, PHONE 92 95 87.688886 $2192.2200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 139 144 997.390471 $49869.5600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 4.142857 $207.1500 $50.0000
INTR -T1013 INTERPRETER 1 2 4.000000 $200.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 59 60 361.428570 $25820.4700 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 11 11 52.357143 $3740.4000 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 44 44 284.678571 $16283.6200 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 4 4 21.857142 $1250.2300 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 18 19 122.142856 $8725.8700 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 3 3 10.285715 $734.8100 $71.4400
PHY -97110HM PT SESSION BY PT ASST 24 25 189.000002 $10803.2400 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 2 2 5.571428 $318.4700 $57.1600
SENS -V5060 BEHIND EAR HEARING AID 2 2 1.394521 $317.9500 $228.0000
SENS -V5264 EARMOLD 3 3 2.355555 $42.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 88 93 551.428566 $39394.0500 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 6 6 45.714286 $3265.8300 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 7 7 51.999999 $3714.8900 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 7.428571 $530.7000 $71.4400
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Subtotal (Total Children Is Unduplicated) 296 1027 3163.348463 $188861.9900 $59.7000
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Total 1875 6517.846481 $332417.0600 $51.0000
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Number of Children (Unduplicated) With at Least One Authorization 500