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: 10-01-19 and 12-31-19 Date of Report: 02-01-20 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1161 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 20 20 13.788888 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 20 20 13.788888 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 25 32 16.918109 $845.9100 $50.0000
EXIT -EXIT EXIT ASSESSMENT 30 31 46.134855 $2306.7400 $50.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 8 8 16.000000 $1200.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 7 7 14.000000 $1050.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 8 9 16.005479 $888.3100 $55.5000
OCTF -97168 OT RE-EVAL EST PLAN CARE 2 2 0.361111 $18.4300 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.172222 $8.7900 $51.0400
OCTH -97167 OT EVAL HIGH COMPLEXITY 2 2 1.227778 $62.6800 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 2 0.544444 $27.7900 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 7 7 1.977778 $100.9700 $51.0500
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Subtotal (Total Children Is Unduplicated) 81 104 118.341776 $6860.6600 $57.9700
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.511111 $25.5600 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 7 8 4.105557 $205.2900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 1.800000 $45.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 157 169 122.433326 $6121.6300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 148 161 185.588889 $4639.7200 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 96 184 113.199987 $5659.9400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 60 100 122.833333 $3070.8300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 35 66 49.477778 $2473.8900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 21 38 47.612700 $1190.3200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 134 141 96.672222 $4833.6100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 133 144 156.633335 $3915.8400 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 0.142857 $3.5700 $25.0100
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 9 9 45.285715 $2264.2900 $50.0000
INTR -T1013 INTERPRETER 1 1 12.571429 $628.5700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 4 4 21.571429 $1541.0600 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 6.571429 $375.8800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 1 1 1.571429 $112.2600 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 5.857143 $334.7900 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 5 5 46.000001 $3286.2300 $71.4400
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Subtotal (Total Children Is Unduplicated) 244 1037 1040.439670 $40728.2800 $39.1500
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Total 1161 1172.570334 $47588.9400 $40.5900
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Number of Children (Unduplicated) With at Least One Authorization 308