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: 10-01-21 and 12-31-21 Date of Report: 02-04-22 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 838 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 17 18 175.338889 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 44.000000 $1628.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 18 19 219.338889 $1628.0000 $7.4200
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 18 20 27.221003 $1361.0500 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 2 3 6.000000 $300.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 47 47 90.000000 $4500.0000 $50.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 0.144444 $7.3700 $51.0300
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 0.172222 $8.7900 $51.0400
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Subtotal (Total Children Is Unduplicated) 70 74 127.537669 $6438.2100 $50.4800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.450000 $2250.0000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 2.333333 $116.6700 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.488889 $24.4500 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.488889 $112.4500 $230.0100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 2 2.000000 $100.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 4 5 0.922223 $23.0600 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 110 116 70.662706 $3533.1700 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 1.000000 $50.0000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 106 114 103.416668 $2585.4200 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 68 129 57.922227 $2896.1400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 48 89 56.644439 $1416.1000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 19 36 15.522224 $776.1200 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 20 37 34.744443 $868.6100 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 91 94 61.861117 $3093.0900 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 0.388889 $19.4500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 101 105 89.783337 $2244.5900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 8.678571 $216.9700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1 2 2.571429 $128.5700 $50.0000
INTR -T1013 INTERPRETER 1 1 1.000000 $50.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 3 3 15.285714 $1092.0200 $71.4400
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 1.000000 $456.0000 $456.0000
SENS -V5264 EARMOLD 1 1 0.488889 $8.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 3 18.000000 $1285.9200 $71.4400
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Subtotal (Total Children Is Unduplicated) 220 745 545.653987 $23347.5600 $42.7900
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Total 838 892.530545 $31413.7700 $35.2000
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Number of Children (Unduplicated) With at Least One Authorization 271