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: 10-01-23 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 775 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 60 60 3525.899999 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 5 5 536.000000 $19939.2000 $37.2000
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Subtotal (Total Children Is Unduplicated) 65 65 4061.899999 $19939.2000 $4.9100
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 2 2 0.622223 $31.1200 $50.0100
EVAL -96111GT DEVELOPMENTAL EVALUATION 1 1 1.000000 $50.0000 $50.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 0.109590 $8.2200 $75.0100
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 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 12 12 24.000000 $1800.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 9 9 18.000000 $1350.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 3 3 6.000000 $333.0000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
OCTF -97168 OT RE-EVAL EST PLAN CARE 4 4 0.805556 $41.4200 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 5 5 5.077778 $261.0500 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 2 0.461111 $23.7100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 0.033333 $1.7100 $51.3600
SPCH -92521 EVAL OF SPEECH FLUENCY 3 3 2.038889 $104.8200 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 10 10 4.561110 $234.4800 $51.4100
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Subtotal (Total Children Is Unduplicated) 41 62 78.709590 $5322.5200 $67.6200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 5 5.238889 $26194.5000 $5000.0100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 16 16 13.677778 $683.8900 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 1 2 2.000000 $100.0000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 108 119 68.682543 $3434.1400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 47 49 54.277777 $1356.9400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 91 151 86.150006 $4307.5300 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 1 2 1.977778 $98.8900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 32 62 64.555555 $1613.8900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 26 51 23.755561 $1187.8100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 12 23 21.877778 $546.9500 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 69 71 41.995238 $2099.7700 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 1 1 0.144444 $7.2200 $49.9800
CONSP -CONSP CONSULT, SLP, PHONE 44 46 46.355555 $1158.8900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 9 9 52.428572 $2621.4300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 7 8 26.537302 $1909.6200 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 8 9 43.714285 $2517.9400 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 0.857143 $49.3700 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 1 1 10.571429 $760.7200 $71.9600
PHY -97110HM PT SESSION BY PT ASST 4 4 11.857143 $682.4900 $57.5600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 15 17 86.785715 $6245.1000 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 10.428571 $750.4400 $71.9600
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Subtotal (Total Children Is Unduplicated) 197 648 673.869062 $58327.5000 $86.5600
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Total 775 4814.478651 $83589.2200 $17.3600
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Number of Children (Unduplicated) With at Least One Authorization 276