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: 10-01-21 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 1851 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 9 9 13.427779 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 39 40 4455.933333 $164869.5300 $37.0000
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Subtotal (Total Children Is Unduplicated) 46 49 4469.361112 $164869.5300 $36.8900
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 0.555555 $63.8800 $114.9900
EVAL -96111 DEVELOPMENTAL EVALUATION 20 22 27.792922 $1389.6500 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 2 3 6.000000 $300.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 33 33 58.000000 $2900.0000 $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 25 25 50.000000 $3750.0000 $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 15 15 30.000000 $2250.0000 $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 37 41 22.718253 $1159.7700 $51.0500
OCTF -97168GT OT RE-EVAL EST PLAN CARE 2 2 1.100000 $56.1600 $51.0500
OCTF -97168TLGT OT RE-EVAL EST PLAN CARE 1 1 0.188889 $9.6400 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.005556 $0.2900 $51.4600
OCTH -97166 OT EVAL MODERATE COMPLEXITY 5 5 3.727778 $190.3000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 47 48 27.366286 $1397.0500 $51.0500
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 34 35 12.000003 $612.6200 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.250000 $12.7600 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 18 20 11.133334 $568.3600 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 94 95 39.185714 $2000.4400 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 6 6 1.666666 $85.0800 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 4 4 0.794445 $35.4000 $44.5500
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Subtotal (Total Children Is Unduplicated) 406 726 1020.199686 $67514.0100 $66.1800
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 0.888889 $44.4500 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 2 2.000000 $100.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 0.855556 $21.3900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 93 96 68.410320 $3420.5300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 78 80 91.466667 $2286.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 72 140 76.633336 $3831.6800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 38 70 75.133335 $1878.3400 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 22 44 27.966664 $1398.3200 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 16 32 34.144445 $853.6100 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 76 78 53.294447 $2664.7400 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 0.388889 $19.4500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 77 80 85.244445 $2131.1100 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 9.142857 $228.5700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 115 118 837.852374 $41892.6600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 5 5 17.571429 $878.5800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 65 71 405.428569 $28963.8500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 79 85 747.714286 $42769.2700 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 2 2 11.857143 $678.2300 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 28 32 170.571426 $12185.6400 $71.4400
PHY -97110HM PT SESSION BY PT ASST 30 31 321.857145 $18397.3300 $57.1600
SENS -V5060 BEHIND EAR HEARING AID 1 1 1.000000 $228.0000 $228.0000
SENS -V5264 EARMOLD 2 2 0.555555 $10.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 91 95 740.571424 $52906.4700 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 11.357142 $811.3500 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 3 3 43.714286 $3122.9500 $71.4400
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Subtotal (Total Children Is Unduplicated) 299 1076 3835.620629 $221723.1700 $57.8100
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Total 1851 9325.181427 $454106.7100 $48.7000
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Number of Children (Unduplicated) With at Least One Authorization 497