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: 07-01-22 and 06-30-23 Date of Report: 07-25-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 8246 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 122 138 7707.776188 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 143 153 112878.769842 $4199090.2400 $37.2000
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Subtotal (Total Children Is Unduplicated) 261 291 120586.546030 $4199090.2400 $34.8200
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 82 109 164.912329 $8245.6200 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 16 20 31.031202 $1551.5600 $50.0000
EXIT -EXIT EXIT ASSESSMENT 42 42 77.677777 $3883.8900 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 7 9 18.000000 $1350.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 58 59 112.027701 $8402.0800 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 6 6 12.000000 $900.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 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 -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 26 26 52.000000 $3900.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 5 5 10.000000 $750.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 2.005479 $150.4100 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 24 24 44.022222 $2443.2300 $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 763 773 1537.133334 $115285.0100 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 190 192 383.000000 $28725.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 124 124 245.066667 $18380.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 30 30 60.000000 $4500.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 209 209 418.000000 $31350.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 55 55 110.000000 $8250.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 469 474 946.066667 $52506.7000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 103 104 208.000000 $11544.0000 $55.5000
OCTF -97168 OT RE-EVAL EST PLAN CARE 146 214 154.822224 $7959.4200 $51.4100
OCTF -97168GT OT RE-EVAL EST PLAN CARE 5 5 3.166667 $162.8000 $51.4100
OCTF -97168TL OT RE-EVAL EST PLAN CARE 1 1 0.350000 $17.9900 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 9 10 11.566667 $594.6400 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 22 31 19.905558 $1023.3600 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 0.427778 $21.9900 $51.4100
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 162 181 192.226205 $9882.3600 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 13 14 12.238890 $629.2100 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 3 3 5.000000 $257.0500 $51.4100
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 2 3 4.000000 $205.6400 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 83 115 125.882544 $6471.6400 $51.4100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 4 6 4.533334 $233.0600 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 3 3 3.000000 $154.2300 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 7 15 8.933334 $459.2700 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 57 68 58.083333 $2986.0600 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 5 5 3.238889 $166.5100 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 3 3 3.000000 $154.2300 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 22 24 20.238891 $1040.4900 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 2 2 2.016667 $103.6800 $51.4100
SPCH -92522TLGT EVAL OF SPCH SOUND PROD 1 1 0.533333 $27.4200 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 273 376 275.008742 $14138.2600 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 4 5 2.694444 $138.5200 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 5 7 3.916667 $201.3600 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.850000 $43.7000 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.272222 $13.9900 $51.4100
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Subtotal (Total Children Is Unduplicated) 1477 3371 5369.849767 $350819.6200 $65.3300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 5 4.338888 $21694.0000 $4999.9000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 3 2.366667 $118.3400 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 3 6 5.911111 $1369.1300 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 46 67 50.719449 $2536.0000 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 3 8 8.000000 $400.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 12 13 35.052779 $876.3200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 350 525 747.399999 $37370.0000 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 5 5 4.433334 $221.6700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 211 295 868.445244 $21711.1500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 202 519 628.983337 $31449.1900 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 2 6 9.688888 $484.4400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 95 260 631.077771 $15776.9300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 70 205 274.199998 $13709.9900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 37 118 335.566668 $8389.1700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 323 456 676.475399 $33823.7800 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 5 5 4.055556 $202.7800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 206 283 773.761115 $19344.0400 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 5.571429 $278.5700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 370 580 9132.461894 $456623.1300 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 29 35 441.157144 $22057.8600 $50.0000
INTR -T1013 INTERPRETER 1 1 2.000000 $100.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 154 233 3315.541262 $238586.4100 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 3 4 60.714285 $4369.0000 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 175 280 5639.313486 $324824.4600 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 6 6 120.000000 $6911.9900 $57.6000
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 0.344444 $24.7800 $71.9500
OCCT -97530TLHM OT SESSION BY OT ASST 2 2 125.571428 $7232.9200 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 76 119 1926.500792 $138631.0300 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 3 4 69.857143 $5026.9200 $71.9600
PHY -97110HM PT SESSION BY PT ASST 74 127 2521.592060 $145142.8600 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 1 1 17.571429 $1011.4100 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 1 1 24.571429 $1768.1600 $71.9600
PHY -97110TLHM PT SESSION BY PT ASST 1 1 16.285714 $937.4000 $57.5600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 4 3.277778 $1505.2300 $459.2200
SENS -V5264 EARMOLD 3 6 6.311111 $114.4200 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 244 363 5462.550786 $393085.1900 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 7 8 116.428570 $8378.2000 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 18 23 430.285715 $30963.3700 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 3 5 34.314285 $2469.2600 $71.9600
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Subtotal (Total Children Is Unduplicated) 822 4584 34532.698387 $1999519.4700 $57.9000
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Total 8246 160489.094184 $6549429.3300 $40.8100
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Number of Children (Unduplicated) With at Least One Authorization 1625