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
Eligibility Filter: Program Patients
With the filters selected there were 3397 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 12 13 15.344445 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 49 51 10463.428571 $387146.8600 $37.0000
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Subtotal (Total Children Is Unduplicated) 59 64 10478.773016 $387146.8600 $36.9500
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 20 20 13.592772 $679.6500 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 2 4 8.000000 $400.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 74 75 129.000000 $6450.0000 $50.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 9 9 18.000000 $1350.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 6 6 12.000000 $900.0000 $75.0000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 4 4 6.011111 $333.6200 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 12 12 24.000000 $1800.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 213 217 421.032874 $31577.4800 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 3 3 6.000000 $450.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 30 30 58.005479 $4350.4100 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 3 3 6.000000 $450.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 94 97 191.005479 $14325.4100 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 6 6 12.000000 $666.0000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 93 93 182.010958 $10101.6100 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 4.000000 $300.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 49 51 8.542855 $436.1000 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.172222 $8.7900 $51.0400
OCTH -97166 OT EVAL MODERATE COMPLEXITY 5 5 1.983333 $101.2500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 71 75 23.272225 $1188.0600 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 24 24 81.938891 $4182.9900 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 28 29 16.327778 $833.5300 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 2 3 2.144444 $109.4700 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 151 160 46.539271 $2375.8400 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 0.733333 $37.4400 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 5 6 2.005555 $89.3500 $44.5500
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Subtotal (Total Children Is Unduplicated) 563 939 1274.318580 $83496.9900 $65.5200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 2 0.955556 $4778.0000 $5000.2300
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.466667 $337.3400 $230.0100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 9 10 3.369408 $168.4800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 3 3 2.222222 $55.5600 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 251 275 155.432535 $7771.6000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 227 244 275.344446 $6883.6300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 132 245 111.638891 $5581.9600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 82 141 116.011115 $2900.2900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 30 49 26.633338 $1331.6900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 22 38 29.361110 $734.0300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 221 236 127.205553 $6360.2700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 208 220 227.381748 $5684.5600 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 8 8 48.249999 $1206.2500 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 280 300 1739.857135 $86992.8100 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 69 71 719.285714 $35964.2900 $50.0000
INTR -T1013 INTERPRETER 1 1 2.000000 $100.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 83 85 428.533332 $30614.4300 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 9 9 99.999999 $7144.0100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 111 129 710.609519 $40646.8800 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 17 17 157.142857 $8988.5700 $57.2000
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 12.285714 $877.6900 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 30 30 178.857141 $12777.5600 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 7 7 76.571427 $5470.2700 $71.4400
PHY -97110HM PT SESSION BY PT ASST 28 29 194.428571 $11113.5300 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 1 1 12.571429 $718.5800 $57.1600
SENS -V5264 EARMOLD 1 1 1.466667 $26.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 139 147 935.552373 $66835.9200 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 33 33 311.142856 $22228.0400 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 0.857143 $61.2300 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 2 2 20.285714 $1449.2200 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 9.285714 $128.8900 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 44 56 507.519049 $18778.2100 $37.0000
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Subtotal (Total Children Is Unduplicated) 557 2394 7243.524942 $394710.1500 $54.4900
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Total 3397 18996.616538 $865353.9900 $45.5500
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Number of Children (Unduplicated) With at Least One Authorization 833