Summary Report for FSPSAs Ending During the Report Period Center: 55
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: 10-01-21 and 12-31-21 Date of Report: 02-04-22 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 2111 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 17 18 175.338889 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 65 68 7130.382540 $263824.1500 $37.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 81 86 7305.721429 $263824.1500 $36.1100
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 3.233333 $371.8300 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 18 20 27.221003 $1361.0500 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 2 3 6.000000 $300.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 48 48 92.000000 $4600.0000 $50.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 8 8 16.000000 $1200.0000 $75.0000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 4 4 8.000000 $600.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 6 6 12.000000 $666.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 24 24 48.000000 $3600.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 146 147 292.285714 $21921.4300 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 14 14 28.000000 $2100.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 24 25 48.142857 $3610.7200 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 63 66 130.285714 $9771.4300 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 19 19 38.000000 $2109.0000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 72 72 144.000000 $7992.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 10 14 28.000000 $2100.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $150.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 40 43 17.523016 $894.5500 $51.0500
OCTF -97168GT OT RE-EVAL EST PLAN CARE 2 2 1.166666 $59.5600 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 14 14 9.722223 $496.3200 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 58 61 42.838887 $2186.9200 $51.0500
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 25 25 5.888890 $300.6300 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.472222 $24.1100 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 26 27 15.700000 $801.4900 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.005556 $0.2900 $51.4600
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 101 103 38.869052 $1984.2900 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 1.538889 $78.5600 $51.0500
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 0.400000 $20.4200 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.177778 $7.9200 $44.5600
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 445 763 1066.471800 $69920.5500 $65.5600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.450000 $2250.0000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 2 3.200000 $160.0000 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.488889 $24.4500 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 0.955556 $219.7900 $230.0100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 2 2.000000 $100.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 4 5 0.922223 $23.0600 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 110 116 70.662706 $3533.1700 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 1.000000 $50.0000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 106 114 103.416668 $2585.4200 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 68 129 57.922227 $2896.1400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 48 89 56.644439 $1416.1000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 19 36 15.522224 $776.1200 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 20 37 34.744443 $868.6100 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 91 94 61.861117 $3093.0900 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 0.388889 $19.4500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 101 105 89.783337 $2244.5900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 8.678571 $216.9700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 154 163 1016.285705 $50814.3200 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 5 6 26.785715 $1339.2900 $50.0000
INTR -T1013 INTERPRETER 1 1 1.000000 $50.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 79 86 435.199995 $31090.7300 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 5.428571 $387.8200 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 76 81 546.785713 $31276.1300 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 2 2 6.714285 $384.0600 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 32 35 205.999996 $14716.6500 $71.4400
PHY -97110HM PT SESSION BY PT ASST 27 29 197.571425 $11293.1900 $57.1600
SENS -V5060 BEHIND EAR HEARING AID 2 2 1.460274 $332.9500 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 1.000000 $456.0000 $456.0000
SENS -V5264 EARMOLD 5 5 4.655555 $83.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 101 106 636.423802 $45466.1200 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 8 8 64.357142 $4597.6800 $71.4400
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 348 1262 3658.309467 $212765.6600 $58.1600
-------------------------------------------------------------------------------------------------------------------------------------
Total 2111 12030.502696 $546510.3600 $45.4300
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 594