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: 10-01-22 and 12-31-22 Date of Report: 01-23-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 833 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 27 28 1210.600001 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 27 28 1210.600001 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 21 27 32.549925 $1627.5000 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 6 7 10.219178 $510.9600 $50.0000
EXIT -EXIT EXIT ASSESSMENT 10 10 19.000000 $950.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 7 7 14.000000 $1050.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 3 3 6.000000 $450.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 4 5 10.000000 $750.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 3 3 6.000000 $450.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 4.000000 $222.0000 $55.5000
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 0.038889 $2.0000 $51.4200
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.077778 $4.0000 $51.4200
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 0.272222 $13.9900 $51.4100
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Subtotal (Total Children Is Unduplicated) 56 73 112.157992 $6741.4500 $60.1100
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.488889 $24.4500 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 16 20 13.483334 $674.1700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 3 3 5.300000 $132.5000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 125 138 79.327780 $3966.4000 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 0.166667 $8.3400 $50.0100
CONIP -CONIP CONSULT, ITDS PHONE 69 74 86.194443 $2154.8600 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 72 128 63.627780 $3181.4000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 42 78 69.655554 $1741.3900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 28 53 23.744437 $1187.1900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 14 27 21.705555 $542.6400 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 108 116 75.153175 $3757.6600 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 0.166667 $8.3400 $50.0100
CONSP -CONSP CONSULT, SLP, PHONE 68 72 78.333332 $1958.3300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 5 5 23.571428 $1178.5700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 3 3 12.285715 $884.0800 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 5 5 38.285715 $2205.2600 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 1 1 0.714286 $51.4000 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 6 6 35.857144 $2580.2800 $71.9600
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Subtotal (Total Children Is Unduplicated) 214 732 628.061901 $26237.2200 $41.7700
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Total 833 1950.819894 $32978.6700 $16.9100
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Number of Children (Unduplicated) With at Least One Authorization 271