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: 04-01-20 and 06-30-20 Date of Report: 07-20-20 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1340 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 11 12 14.633334 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 3 3 625.000000 $23125.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 14 15 639.633334 $23125.0000 $36.1500
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 15 15 8.187445 $409.3800 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 2 4 8.000000 $400.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 42 42 71.000000 $3550.0000 $50.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 3 3 6.000000 $450.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 4.000000 $222.0000 $55.5000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.111111 $5.6700 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 3 3 0.661111 $33.7500 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 0.355556 $18.1500 $51.0600
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 0.077778 $3.9700 $51.0600
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 5 5 0.804338 $41.0600 $51.0500
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Subtotal (Total Children Is Unduplicated) 73 82 109.197339 $5844.9900 $53.5300
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 6 6 3.083334 $154.1700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 0.500000 $12.5000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 206 223 124.682534 $6234.1000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 185 197 239.083335 $5977.1000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 101 184 86.055554 $4302.7700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 64 109 98.516672 $2462.9300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 27 44 22.944449 $1147.2500 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 20 35 27.427777 $685.6900 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 179 190 100.811109 $5040.5500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 168 178 192.037303 $4800.9500 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 0.285714 $7.1400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 15 15 102.999999 $5150.0000 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 5 5 62.428572 $3121.4300 $50.0000
INTR -T1013 INTERPRETER 1 1 2.000000 $100.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 5 5 23.714286 $1694.1500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 4 4 23.571428 $1348.2800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 1 1 8.857143 $632.7500 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 5.714286 $326.6300 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 5 5 45.857142 $3276.0400 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 12.571429 $898.1000 $71.4400
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 27 37 302.090478 $11177.3600 $37.0000
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Subtotal (Total Children Is Unduplicated) 306 1243 1485.232544 $58549.8700 $39.4200
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Total 1340 2234.063217 $87519.8600 $39.1800
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Number of Children (Unduplicated) With at Least One Authorization 341