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: 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 8160 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 153 167 8947.698409 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 152 171 111777.855554 $4158136.2200 $37.2000
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Subtotal (Total Children Is Unduplicated) 302 338 120725.553963 $4158136.2200 $34.4400
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 81 107 163.219635 $8160.9900 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 19 23 34.118873 $1705.9500 $50.0000
EXIT -EXIT EXIT ASSESSMENT 34 34 61.677777 $3083.8900 $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 765 775 1541.133334 $115585.0100 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 191 193 384.000000 $28800.0000 $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 56 56 111.000000 $8325.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 470 475 948.066667 $52617.7000 $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 137 202 128.631829 $6613.0000 $51.4100
OCTF -97168GT OT RE-EVAL EST PLAN CARE 2 2 1.138889 $58.5500 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 8 9 9.383333 $482.4000 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 28 33 23.466670 $1206.4400 $51.4100
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 152 173 206.645252 $10623.6400 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 14 16 14.616666 $751.4400 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 5 5 7.000000 $359.8700 $51.4100
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 4 4 4.955556 $254.7700 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 74 107 89.122230 $4581.8100 $51.4100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 5 7 4.933334 $253.6300 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 3 3 3.000000 $154.2300 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 6 12 6.911111 $355.3000 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 59 71 65.244447 $3354.2300 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 7 8 9.894445 $508.6800 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 4 4 4.000000 $205.6400 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 23 26 21.405558 $1100.4700 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.4100 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 2 3 2.405556 $123.6700 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 267 361 275.086520 $14142.2600 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 4 6 2.650000 $136.2400 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 7 10 6.155556 $316.4600 $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) 1382 3338 5335.257529 $349211.6000 $65.4500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 7 7.172222 $35861.0000 $4999.9800
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.455556 $22.7800 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 3.266667 $756.6300 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 49 68 50.919450 $2546.0000 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 3 8 8.000000 $400.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 6 7 17.069445 $426.7400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 356 529 787.190480 $39359.5500 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 6 6 4.700001 $235.0100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 185 257 838.100800 $20952.5400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 235 577 670.072201 $33503.5100 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 3 7 8.499999 $425.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 96 240 591.188895 $14779.7400 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 68 212 277.244445 $13862.2300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 35 111 342.111119 $8552.8000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 307 427 667.334130 $33366.7200 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 6 6 4.322223 $216.1200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 181 245 747.694450 $18692.3800 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 11.714286 $585.7200 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 372 560 9178.704736 $458935.3100 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 29 37 402.500000 $20125.0000 $50.0000
INTR -T1013 INTERPRETER 1 1 2.000000 $100.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 164 234 3687.464275 $265350.0200 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 2 3 27.428571 $1973.7600 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 188 284 5847.170624 $336797.0600 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 4 4 102.000000 $5875.2000 $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 3 136.571428 $7866.5200 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 74 114 1922.289681 $138327.9700 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 1 1 25.857143 $1860.6800 $71.9600
PHY -97110HM PT SESSION BY PT ASST 69 124 2527.714283 $145495.2600 $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
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 1.400000 $642.9100 $459.2200
SENS -V5264 EARMOLD 3 3 3.266667 $59.2300 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 248 363 5427.969828 $390596.8300 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 5 6 65.999998 $4749.3700 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 16 25 403.914285 $29065.6700 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 2 4 44.504762 $3202.5600 $71.9600
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Subtotal (Total Children Is Unduplicated) 848 4484 34886.299952 $2038372.1000 $58.4300
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Total 8160 160947.111444 $6545719.9300 $40.6700
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Number of Children (Unduplicated) With at Least One Authorization 1475