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: 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 1980 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 19 25.377779 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 24 24 1700.000000 $62900.0000 $37.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 40 43 1725.377779 $62900.0000 $36.4600
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 12 12 9.422832 $471.1500 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 2 4 8.000000 $400.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 35 35 62.000000 $3100.0000 $50.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 8 8 16.000000 $1200.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 5 5 10.000000 $750.0000 $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 9 9 18.000000 $1350.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 166 169 325.032874 $24377.4800 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 21 21 40.005479 $3000.4100 $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 73 74 145.005479 $10875.4100 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 5 5 10.000000 $555.0000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 74 74 144.010958 $7992.6100 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $150.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 39 42 13.350000 $681.5200 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.172222 $8.7900 $51.0400
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 0.027778 $1.4200 $51.0900
OCTH -97167 OT EVAL HIGH COMPLEXITY 43 48 16.362655 $835.3200 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 15 17 81.033333 $4136.7500 $51.0500
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 0.027778 $1.4200 $51.0900
PSTH -97163 PT EVAL HIGH COMPLEXITY 16 18 6.788890 $346.5800 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 0.261111 $13.3300 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 92 97 42.346411 $2161.7800 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 6 6 2.583333 $131.8800 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 5 5 2.461111 $125.6400 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 5 5 1.927778 $85.8800 $44.5500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 386 669 971.831133 $63737.0300 $65.5800
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.555556 $127.7900 $230.0200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 3 1.761111 $88.0600 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 144 151 90.327777 $4516.3900 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 0.305556 $15.2800 $50.0100
CONIP -CONIP CONSULT, ITDS PHONE 122 128 132.983333 $3324.5800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 75 125 59.500798 $2975.0700 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 1 1 0.277778 $13.8900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 38 63 71.763493 $1794.0900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 24 43 18.700002 $935.0100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 24 43 29.044446 $726.1200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 121 123 77.544445 $3877.2300 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 0.316667 $15.8400 $50.0100
CONSP -CONSP CONSULT, SLP, PHONE 105 107 98.122224 $2453.0600 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 3.571429 $89.2900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 154 163 953.428572 $47671.4400 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 18 19 117.000001 $5850.0000 $50.0000
INTR -T1013 INTERPRETER 2 2 22.571429 $1128.5700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 46 47 287.178570 $20516.0300 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 4 4 20.000000 $1428.8000 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 58 62 373.576190 $21368.5600 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 4 4 13.428573 $768.1100 $57.2000
OCCT -97530TLGT OT SESSION BY LICENSED OT 2 2 13.000000 $928.7200 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 18 18 113.857143 $8133.9400 $71.4400
PHY -97110HM PT SESSION BY PT ASST 25 25 155.678571 $8898.5900 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 1 1 0.714286 $40.8300 $57.1600
SENS -V5264 EARMOLD 1 1 0.555556 $10.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 97 102 610.571430 $43619.2200 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 6 7 79.714286 $5694.7900 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 4 4 22.428572 $1602.2900 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 3 3 15.142857 $1081.8100 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 8.000000 $111.0400 $13.8800
SPL -92508TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 1.857143 $25.7800 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 8 10 87.219842 $3227.1400 $37.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 351 1268 3480.697636 $193057.3200 $55.4700
-------------------------------------------------------------------------------------------------------------------------------------
Total 1980 6177.906548 $319694.3400 $51.7500
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 510