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: 10-01-19 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 2813 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 15 15 16.722221 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 40 40 7263.857143 $268762.7100 $37.0000
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Subtotal (Total Children Is Unduplicated) 52 55 7280.579364 $268762.7100 $36.9200
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 23 30 15.691169 $784.5600 $50.0000
EXIT -EXIT EXIT ASSESSMENT 28 29 43.070471 $2153.5200 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 11 11 20.011111 $1500.8300 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 13 13 20.027701 $1502.0800 $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 7 7 10.016590 $555.9200 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 214 215 418.032874 $31352.4800 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 170 171 336.016437 $25201.2400 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 73 73 132.038353 $9902.8900 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 71 72 136.021916 $7549.2200 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 16 16 32.000000 $2400.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 37 38 8.472218 $432.4900 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.172222 $8.7900 $51.0400
OCTH -97166 OT EVAL MODERATE COMPLEXITY 11 11 1.999999 $102.1000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 52 55 22.533332 $1150.3200 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 20 22 5.577777 $284.7400 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 0.894444 $45.6600 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 21 24 6.872224 $350.8400 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 109 116 31.411112 $1603.5400 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 0.444444 $21.7500 $48.9400
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Subtotal (Total Children Is Unduplicated) 503 912 1245.304394 $87202.9500 $70.0300
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.600000 $138.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 9 10 7.150001 $357.5100 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 216 227 160.333330 $8016.6500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 196 204 227.172220 $5679.3000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 113 204 119.466663 $5973.3200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 72 126 128.822235 $3220.5900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 33 58 34.461109 $1723.0500 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 24 42 46.311115 $1157.7900 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 185 188 127.483332 $6374.1600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 178 183 188.338891 $4708.4800 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 19.142857 $478.5700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 249 260 1781.666688 $89083.2700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 69 75 347.727779 $24841.6500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 96 105 677.571435 $38757.0900 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 30 31 196.932143 $14068.8400 $71.4400
PHY -97110HM PT SESSION BY PT ASST 29 31 194.000003 $11089.0400 $57.1600
SENS -V5264 EARMOLD 1 1 0.600000 $10.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 93 97 669.247624 $47811.0100 $71.4400
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Subtotal (Total Children Is Unduplicated) 425 1846 4927.027425 $263489.0900 $53.4800
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Total 2813 13452.911183 $619454.7600 $46.0500
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Number of Children (Unduplicated) With at Least One Authorization 615