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
Eligibility Filter: Program Patients
With the filters selected there were 3572 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 17 17 17.733332 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 54 54 10196.857143 $377283.7100 $37.0000
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Subtotal (Total Children Is Unduplicated) 67 71 10214.590475 $377283.7100 $36.9400
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 29 37 19.141169 $957.0600 $50.0000
EXIT -EXIT EXIT ASSESSMENT 43 47 63.826026 $3191.3000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 12 12 22.011111 $1650.8300 $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 8 8 12.016590 $666.9200 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 272 273 530.043832 $39753.3000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 222 224 432.043832 $32403.3000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 87 87 160.038353 $12002.8900 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 91 92 170.038353 $9437.1400 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 20 20 40.000000 $3000.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 51 52 11.522219 $588.1900 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.172222 $8.7900 $51.0400
OCTH -97166 OT EVAL MODERATE COMPLEXITY 16 16 5.349999 $273.1100 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 64 67 27.183332 $1387.7000 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 27 29 6.277777 $320.4800 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.172222 $8.7900 $51.0400
PSTH -97162 PT EVAL MODERATE COMPLEXITY 4 4 1.894444 $96.7100 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 25 28 7.588891 $387.4200 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 134 143 38.694443 $1975.3400 $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) 648 1160 1573.486960 $109984.1500 $69.9000
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 10 12 7.161113 $358.0700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 0.505555 $12.6400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 262 277 196.177771 $9808.8600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 246 257 282.438884 $7060.9600 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 144 257 150.555552 $7527.7600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 88 152 150.816680 $3770.4500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 38 67 43.511106 $2175.5300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 27 47 57.927780 $1448.2000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 229 233 158.283329 $7914.1500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 225 232 234.211111 $5855.2800 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 6 6 33.714285 $842.8600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 317 331 2278.166686 $113908.2900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 101 108 515.727778 $36843.5800 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 129 140 915.392863 $52360.4700 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 40 43 258.075000 $18436.8900 $71.4400
PHY -97110HM PT SESSION BY PT ASST 35 38 253.428573 $14485.9800 $57.1600
SENS -V5264 EARMOLD 1 1 0.600000 $10.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 132 136 931.176197 $66523.1900 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 10.285714 $142.7700 $13.8800
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Subtotal (Total Children Is Unduplicated) 560 2341 6478.755977 $349624.7100 $53.9600
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Total 3572 18266.833412 $836892.5700 $45.8100
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Number of Children (Unduplicated) With at Least One Authorization 805