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: 10-01-22 and 12-31-22 Date of Report: 01-23-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1919 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 27 28 1210.600001 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 48 48 11219.415874 $417362.2700 $37.2000
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Subtotal (Total Children Is Unduplicated) 74 76 12430.015875 $417362.2700 $33.5800
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 22 28 34.549925 $1727.5000 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 6 7 10.219178 $510.9600 $50.0000
EXIT -EXIT EXIT ASSESSMENT 11 11 19.644444 $982.2200 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 17 17 34.000000 $2550.0000 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 2 2 4.000000 $300.0000 $75.0000
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 9 9 18.000000 $1350.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 5 5 10.000000 $555.0000 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 121 125 250.000000 $18750.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 43 43 86.000000 $6450.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 20 20 40.000000 $3000.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 4 4 8.000000 $600.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 29 30 60.000000 $4500.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 15 15 30.000000 $2250.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 66 67 134.000000 $7437.0000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 25 26 52.000000 $2886.0000 $55.5000
OCTF -97168 OT RE-EVAL EST PLAN CARE 48 49 16.392062 $842.7100 $51.4100
OCTF -97168GT OT RE-EVAL EST PLAN CARE 1 1 0.216667 $11.1400 $51.4200
OCTH -97165 OT EVAL LOW COMPLEXITY 4 4 3.083333 $158.5100 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 9 9 1.422221 $73.1100 $51.4100
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 34 35 23.924961 $1229.9700 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 3 3 1.661112 $85.4000 $51.4100
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 2 2 3.000000 $154.2300 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 25 26 13.902380 $714.7100 $51.4100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 2 2 0.238889 $12.2800 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 0.555556 $28.5600 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 15 16 8.494445 $436.7000 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 4 4 2.461111 $126.5300 $51.4100
SPCH -92522TLGT EVAL OF SPCH SOUND PROD 1 1 0.022222 $1.1400 $51.3600
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 93 96 38.169836 $1962.2800 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.177778 $9.1400 $51.4200
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.338889 $17.4200 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.177778 $7.9800 $44.8700
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Subtotal (Total Children Is Unduplicated) 395 670 916.652787 $60534.3200 $66.0400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 2 2.000000 $10000.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.488889 $24.4500 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 1.000000 $231.6200 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 16 20 13.483334 $674.1700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 3 3 5.300000 $132.5000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 125 138 79.327780 $3966.4000 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 0.166667 $8.3400 $50.0100
CONIP -CONIP CONSULT, ITDS PHONE 69 74 86.194443 $2154.8600 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 72 128 63.627780 $3181.4000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 42 78 69.655554 $1741.3900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 28 53 23.744437 $1187.1900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 14 27 21.705555 $542.6400 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 108 116 75.153175 $3757.6600 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 0.166667 $8.3400 $50.0100
CONSP -CONSP CONSULT, SLP, PHONE 68 72 78.333332 $1958.3300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 142 154 1021.071430 $51053.5700 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 3 3 26.857143 $1342.8600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 49 51 221.173019 $15915.5900 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 10.285714 $740.1700 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 71 75 595.142859 $34280.2700 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 2 2 16.285714 $938.0600 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 28 30 143.471430 $10324.1900 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 1 1 8.142857 $585.9600 $71.9600
PHY -97110HM PT SESSION BY PT ASST 33 35 234.503176 $13498.0000 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 1 1 5.142857 $296.0300 $57.5600
PHY -97110TLHM PT SESSION BY PT ASST 1 1 3.142857 $180.9100 $57.5600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 0.744445 $341.8900 $459.2500
SENS -V5264 EARMOLD 2 2 1.000000 $18.1300 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 85 88 638.142860 $45920.7800 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 26.857143 $1932.6400 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 6 6 25.428572 $1829.8400 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 5.466667 $393.3800 $71.9600
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Subtotal (Total Children Is Unduplicated) 316 1173 3503.206356 $209161.5100 $59.7100
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Total 1919 16849.875018 $687058.1000 $40.7800
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Number of Children (Unduplicated) With at Least One Authorization 549