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 1288 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 3 3 217.000000 $8029.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 20 22 242.377779 $8029.0000 $33.1300
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 13 13 12.906394 $645.3300 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 2 4 8.000000 $400.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 53 54 99.000000 $4950.0000 $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 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 -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 11 11 22.000000 $1221.0000 $55.5000
OCTF -97168 OT RE-EVAL EST PLAN CARE 4 4 0.772223 $39.4300 $51.0600
OCTH -97167 OT EVAL HIGH COMPLEXITY 3 5 0.783334 $39.9900 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 2 0.372223 $19.0100 $51.0600
PSTH -97163 PT EVAL HIGH COMPLEXITY 5 5 1.477778 $75.4400 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 8 8 1.448783 $73.9700 $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) 102 120 172.938513 $9422.0800 $54.4800
EI Services, Class # 03
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 2 2 12.642857 $316.0700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 44 46 258.509525 $12925.4800 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 2 2 22.571428 $1128.5800 $50.0000
INTR -T1013 INTERPRETER 2 2 22.571429 $1128.5700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 7 7 33.857143 $2418.7500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 4 5 31.642857 $1809.9700 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 2 2 16.571429 $1183.8600 $71.4400
PHY -97110HM PT SESSION BY PT ASST 3 3 15.285715 $873.7300 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 17 17 97.571431 $6970.4900 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 10.142857 $724.6100 $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 12 15 139.219842 $5151.1400 $37.0000
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Subtotal (Total Children Is Unduplicated) 310 1146 1398.460709 $61535.1100 $44.0000
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Total 1288 1813.777001 $78986.1900 $43.5500
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Number of Children (Unduplicated) With at Least One Authorization 382