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 3381 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 149 163 8807.298409 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 6 8 5465.000000 $203298.0000 $37.2000
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Subtotal (Total Children Is Unduplicated) 155 171 14272.298409 $203298.0000 $14.2400
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 79 104 158.252968 $7912.6500 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 19 23 34.118873 $1705.9500 $50.0000
EXIT -EXIT EXIT ASSESSMENT 33 33 61.033333 $3051.6700 $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 10 5.944445 $305.6100 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 14 16 17.705557 $910.2500 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 3 3 2.027778 $104.2500 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 5 6 3.344445 $171.9400 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 3 4 2.350000 $120.8100 $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 16 17 8.844444 $454.6900 $51.4100
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Subtotal (Total Children Is Unduplicated) 225 359 577.632954 $34882.8400 $60.3900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 4 4.161111 $20805.5000 $4999.9900
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.455556 $22.7800 $50.0000
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 24 32 572.571427 $28628.5700 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 2 2 29.428571 $1471.4300 $50.0000
INTR -T1013 INTERPRETER 1 1 2.000000 $100.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 19 22 346.226189 $24914.4500 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 21 28 494.428569 $28479.0800 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 52.285714 $3011.6600 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 9 12 243.142858 $17496.5700 $71.9600
PHY -97110HM PT SESSION BY PT ASST 8 13 232.142857 $13362.1500 $57.5600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 26 33 447.785711 $32222.6800 $71.9600
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Subtotal (Total Children Is Unduplicated) 577 2851 7450.790487 $358418.8700 $48.1000
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Total 3381 22300.721850 $596599.7100 $26.7500
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Number of Children (Unduplicated) With at Least One Authorization 764