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
Eligibility Filter: Program Patients
With the filters selected there were 2629 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 28 28 1924.000000 $71188.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 44 47 1949.377779 $71188.0000 $36.5200
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 14 14 12.922832 $646.1500 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 2 4 8.000000 $400.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 62 63 112.000000 $5600.0000 $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 214 218 423.032874 $31727.4800 $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 94 94 184.010958 $10212.6100 $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 50 54 15.722223 $802.6200 $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 54 62 21.390433 $1091.9900 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 19 21 81.938890 $4182.9900 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 1.416667 $72.3200 $51.0500
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 0.027778 $1.4200 $51.0900
PSTH -97163 PT EVAL HIGH COMPLEXITY 26 29 11.755556 $600.1200 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 3 4 2.261111 $115.4300 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 120 128 53.337052 $2722.8600 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 8 8 2.811111 $143.5100 $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 6 6 2.105556 $93.8000 $44.5500
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Subtotal (Total Children Is Unduplicated) 514 888 1273.416221 $83525.6300 $65.5900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 3 1.055556 $5278.0000 $5000.2100
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.555556 $127.7900 $230.0200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 7 10 2.613852 $130.7000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 0.066667 $1.6700 $25.0100
CONIF -CONIF CONSULT, ITDS FACE TO FACE 186 195 117.061113 $5853.0700 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 0.305556 $15.2800 $50.0100
CONIP -CONIP CONSULT, ITDS PHONE 155 162 157.127777 $3928.1900 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 101 178 88.523025 $4426.2000 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 1 1 0.277778 $13.8900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 49 81 85.741274 $2143.5400 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 29 52 20.433337 $1021.6900 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 1 2 0.677778 $33.8900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 28 53 36.388892 $909.7300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 161 164 104.350001 $5217.5100 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 2 2 0.583334 $29.1700 $50.0100
CONSP -CONSP CONSULT, SLP, PHONE 139 141 121.866669 $3046.6700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 16.214286 $405.3600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 198 209 1216.366670 $60818.3500 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 20 21 134.285715 $6714.2800 $50.0000
INTR -T1013 INTERPRETER 2 2 22.571429 $1128.5700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 62 63 377.749998 $26986.4600 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 4 4 20.000000 $1428.8000 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 79 87 512.361903 $29307.1100 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 5 5 17.285716 $988.7400 $57.2000
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 9.000000 $642.9600 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 2 2 13.000000 $928.7200 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 25 25 159.857143 $11420.1900 $71.4400
PHY -97110HM PT SESSION BY PT ASST 33 34 190.859525 $10909.5400 $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 140 147 845.252386 $60384.8000 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 12 14 145.285715 $10379.2100 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 5 5 31.428572 $2245.2500 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 4 4 16.142857 $1153.2500 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 8.714286 $120.9500 $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 12 15 139.219842 $5151.1400 $37.0000
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Subtotal (Total Children Is Unduplicated) 463 1694 4616.351193 $263367.2600 $57.0500
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Total 2629 7839.145193 $418080.8900 $53.3300
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Number of Children (Unduplicated) With at Least One Authorization 674