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: 01-01-23 and 03-31-23 Date of Report: 04-20-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 904 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 37 37 603.266665 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 200.000000 $7440.0000 $37.2000
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Subtotal (Total Children Is Unduplicated) 38 38 803.266665 $7440.0000 $9.2600
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 12 14 22.005556 $1100.2800 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 3 3 4.322222 $216.1100 $50.0000
EXIT -EXIT EXIT ASSESSMENT 4 4 8.000000 $400.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 4 4 8.000000 $600.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH 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 17 17 34.000000 $2550.0000 $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 4 4 8.000000 $600.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 8 8 16.000000 $1200.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 7 7 14.000000 $777.0000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
OCTF -97168 OT RE-EVAL EST PLAN CARE 3 3 0.961111 $49.4100 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 3 3 1.738889 $89.4000 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 0.483333 $24.8500 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 0.377778 $19.4200 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 0.366666 $18.8500 $51.4000
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Subtotal (Total Children Is Unduplicated) 51 78 130.255555 $8467.3100 $65.0100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 13 13 8.311112 $415.5600 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 2 4 4.000000 $200.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 148 164 88.431744 $4421.5800 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 0.450000 $22.5000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 81 85 100.366668 $2509.1700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 82 156 81.142852 $4057.1200 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 1 1 0.177778 $8.8900 $50.0100
CONOP -CONOP CONSULT, OT, PHONE 25 51 58.733332 $1468.3300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 19 38 17.316665 $865.8300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 7 14 17.122222 $428.0600 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 127 136 72.772224 $3638.6200 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 0.222222 $11.1100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 76 78 95.394444 $2384.8600 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 5.571429 $278.5700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 10 10 77.142858 $3857.1500 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 5 5 24.478572 $1761.4800 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 10 10 102.000000 $5875.1900 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 4 4 25.285714 $1819.5700 $71.9600
PHY -97110HM PT SESSION BY PT ASST 2 3 23.857142 $1373.2200 $57.5600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 10 11 62.142859 $4471.8000 $71.9600
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Subtotal (Total Children Is Unduplicated) 230 788 866.919837 $44893.6000 $51.7900
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Total 904 1800.442057 $60800.9100 $33.7700
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Number of Children (Unduplicated) With at Least One Authorization 282