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: 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 702 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 9 9 13.427779 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 9 9 13.427779 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 19 21 26.792922 $1339.6500 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 2 3 6.000000 $300.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 32 32 56.000000 $2800.0000 $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
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 0.172222 $8.7900 $51.0400
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Subtotal (Total Children Is Unduplicated) 56 59 92.965144 $4709.4400 $50.6600
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.733333 $36.6700 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 2 2.000000 $100.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 0.855556 $21.3900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 93 96 68.410320 $3420.5300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 78 80 91.466667 $2286.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 72 140 76.633336 $3831.6800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 38 70 75.133335 $1878.3400 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 22 44 27.966664 $1398.3200 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 16 32 34.144445 $853.6100 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 76 78 53.294447 $2664.7400 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 0.388889 $19.4500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 77 80 85.244445 $2131.1100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1 1 2.000000 $100.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 10.142857 $724.6100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 3.285714 $187.9400 $57.2000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 4 4 28.142857 $2010.5300 $71.4400
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Subtotal (Total Children Is Unduplicated) 179 634 559.842865 $21665.5700 $38.7000
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Total 702 666.235788 $26375.0100 $39.5900
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Number of Children (Unduplicated) With at Least One Authorization 236