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: 10-01-22 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 739 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 31 31 1134.342856 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 1328.000000 $49401.6000 $37.2000
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Subtotal (Total Children Is Unduplicated) 33 33 2462.342856 $49401.6000 $20.0600
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 21 26 34.250381 $1712.5200 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 4 5 10.000000 $500.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 8 8 15.000000 $750.0000 $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
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 0.288889 $14.8500 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 5 5 2.627777 $135.0900 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 1.150000 $59.1200 $51.4100
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Subtotal (Total Children Is Unduplicated) 54 74 114.317047 $6855.9900 $59.9700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.188889 $944.5000 $5000.2900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 17 21 13.050001 $652.5100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 2.900000 $72.5000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 107 115 80.338890 $4016.9500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 54 55 66.300000 $1657.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 59 109 55.452775 $2772.6300 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 1 2 1.644444 $82.2200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 31 60 72.599993 $1814.9800 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 30 57 27.977781 $1398.9100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 19 37 46.072219 $1151.8000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 96 100 77.914287 $3895.7200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 53 53 67.294447 $1682.3700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4 4 29.571428 $1478.5800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 3 3 21.857143 $1572.8400 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 4 5 39.571428 $2279.3200 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 1 1 12.428571 $894.3600 $71.9600
PHY -97110HM PT SESSION BY PT ASST 2 2 19.000000 $1093.6400 $57.5600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 6 6 55.999999 $4029.7600 $71.9600
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Subtotal (Total Children Is Unduplicated) 183 632 690.162295 $31491.0700 $45.6300
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Total 739 3266.822198 $87748.6500 $26.8600
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Number of Children (Unduplicated) With at Least One Authorization 246