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 907 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
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 17 19 25.377779 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 11 11 9.406394 $470.3300 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 2 4 8.000000 $400.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 33 33 59.000000 $2950.0000 $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 -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 -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 4.000000 $222.0000 $55.5000
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 0.094444 $4.8200 $51.0300
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 0.177778 $9.0800 $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 0.659894 $33.6900 $51.0600
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 57 64 93.416288 $4993.8900 $53.4600
EI Services, Class # 03
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
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 7 7 40.999999 $2050.0000 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 10.142857 $507.1500 $50.0000
INTR -T1013 INTERPRETER 2 2 22.571429 $1128.5700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 3.714286 $265.3400 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 3.714286 $212.4600 $57.2000
PHY -97110HM PT SESSION BY PT ASST 1 1 2.857143 $163.3100 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 10 10 47.857145 $3418.9100 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 1.857143 $132.6700 $71.4400
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 8 10 87.219842 $3227.1400 $37.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 236 824 801.581760 $31840.1400 $39.7200
-------------------------------------------------------------------------------------------------------------------------------------
Total 907 920.375827 $36834.0200 $40.0200
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 281