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
Eligibility Filter: Program Patients
With the filters selected there were 1656 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
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 50.000000 $1850.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 21 21 63.788888 $1850.0000 $29.0000
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 28 36 19.140331 $957.0200 $50.0000
EXIT -EXIT EXIT ASSESSMENT 41 42 58.743150 $2937.1500 $50.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 22 22 40.010958 $3000.8300 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 21 21 40.005479 $3000.4100 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 4 4 8.000000 $600.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 20 21 34.021916 $1888.2200 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $150.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 7 7 1.750000 $89.3400 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 3 3 0.694444 $35.4500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 6 6 3.322223 $169.6000 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 4 4 0.900000 $45.9500 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.172222 $8.7900 $51.0400
PSTH -97163 PT EVAL HIGH COMPLEXITY 5 6 2.149999 $109.7500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 10 10 2.738889 $139.8200 $51.0500
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Subtotal (Total Children Is Unduplicated) 129 184 213.649611 $13132.3200 $61.4700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 1.128767 $5644.0000 $5000.1500
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.511111 $25.5600 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 8 10 4.116669 $205.8500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 3 3 2.788889 $69.7200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 201 215 152.516660 $7625.8000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 192 207 227.377778 $5684.4500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 133 248 155.099985 $7754.9300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 76 129 160.166663 $4004.1600 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 47 88 61.549998 $3077.4900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 27 49 57.490476 $1437.2600 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 174 182 125.088889 $6254.4500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 175 188 195.955557 $4898.8900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 4 4 28.571429 $714.2900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 64 65 412.785719 $20639.2900 $50.0000
INTR -T1013 INTERPRETER 1 1 12.571429 $628.5700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 21 21 82.714285 $5909.1100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 8 8 59.285715 $3391.1400 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 5 7 20.160715 $1440.2800 $71.4400
PHY -97110HM PT SESSION BY PT ASST 3 3 15.571429 $890.0600 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 19 20 146.285715 $10450.6400 $71.4400
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Subtotal (Total Children Is Unduplicated) 352 1451 1921.737878 $90745.9100 $47.2200
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Total 1656 2199.176377 $105728.2300 $48.0800
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Number of Children (Unduplicated) With at Least One Authorization 446