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 3378 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 118 134 7567.376188 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 6 6 3649.000000 $135742.8000 $37.2000
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Subtotal (Total Children Is Unduplicated) 124 140 11216.376188 $135742.8000 $12.1000
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 80 106 159.945662 $7997.2900 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 16 20 31.031202 $1551.5600 $50.0000
EXIT -EXIT EXIT ASSESSMENT 41 41 77.033333 $3851.6700 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 8 8 16.000000 $1200.0000 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 3 3 6.000000 $450.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 46 46 92.000000 $6900.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 7 8 16.000000 $1200.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 12 12 24.000000 $1800.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 21 21 42.000000 $3150.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 7 7 14.000000 $1050.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 20 20 40.000000 $2220.0000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 5 5 10.000000 $555.0000 $55.5000
OCTF -97168 OT RE-EVAL EST PLAN CARE 8 11 5.711112 $293.6100 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 12 14 16.138890 $829.7100 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 4 6 3.877778 $199.3600 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.588889 $30.2800 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 3 2.183333 $112.2400 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 3 3 5.011111 $257.6200 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 9 11 6.622223 $340.4500 $51.4100
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Subtotal (Total Children Is Unduplicated) 224 355 586.143533 $35299.7800 $60.2200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 1.327777 $6638.5000 $4999.7100
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 3 2.366667 $118.3400 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.400000 $92.6500 $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 17 25 478.999999 $23950.0000 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 26.142857 $1307.1500 $50.0000
INTR -T1013 INTERPRETER 1 1 2.000000 $100.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 12 17 283.823809 $20423.9700 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 14 21 421.714286 $24290.7300 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 52.285714 $3011.6600 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 7 13 258.714287 $18617.0800 $71.9600
PHY -97110HM PT SESSION BY PT ASST 7 9 175.857143 $10122.3400 $57.5600
SENS -V5264 EARMOLD 1 1 0.800000 $14.5000 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 17 22 359.285711 $25854.2100 $71.9600
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Subtotal (Total Children Is Unduplicated) 546 2883 7117.149216 $321115.1200 $45.1200
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Total 3378 18919.668937 $492157.7000 $26.0100
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Number of Children (Unduplicated) With at Least One Authorization 722