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 1813 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 7 7 1851.000000 $68487.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 18 19 1865.633334 $68487.0000 $36.7100
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 17 17 10.576334 $528.8300 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 2 4 8.000000 $400.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 63 63 110.000000 $5500.0000 $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 7 7 14.000000 $1050.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 2 2 4.000000 $300.0000 $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 11 11 22.000000 $1221.0000 $55.5000
OCTF -97168 OT RE-EVAL EST PLAN CARE 5 5 1.655556 $84.5200 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.111111 $5.6700 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 8 8 2.011111 $102.6700 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 3 3 0.722223 $36.8700 $51.0600
PSTH -97163 PT EVAL HIGH COMPLEXITY 4 4 2.027778 $103.5200 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 10 10 2.765449 $141.1800 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.177778 $7.9200 $44.5600
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Subtotal (Total Children Is Unduplicated) 122 142 190.047340 $10343.1700 $54.4200
EI Services, Class # 03
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 131 243 111.038891 $5551.9600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 82 140 115.561115 $2889.0400 $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 5 5 23.107143 $577.6800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 65 68 431.285709 $21564.2800 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 13 13 149.285714 $7464.2900 $50.0000
INTR -T1013 INTERPRETER 1 1 2.000000 $100.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 14 14 54.714285 $3908.7900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 10 11 80.142857 $4584.1700 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 2 2 24.285714 $1389.1400 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 4 4 18.857143 $1347.1500 $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 13 13 124.428570 $8889.1900 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 6 6 64.142857 $4582.3600 $71.4400
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 44 56 507.519049 $18778.2100 $37.0000
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Subtotal (Total Children Is Unduplicated) 401 1652 2559.033693 $110942.6700 $43.3500
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Total 1813 4614.714367 $189772.8400 $41.1200
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Number of Children (Unduplicated) With at Least One Authorization 460