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: 10-01-20 and 12-31-20 Date of Report: 01-23-21 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1962 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 28 28 48.876191 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 25 25 2626.000000 $97162.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 52 53 2674.876191 $97162.0000 $36.3200
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 22 24 26.702282 $1335.1100 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 2 3 6.000000 $300.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 36 37 68.142857 $3407.1500 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 6.000000 $450.0000 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 7 7 14.000000 $1050.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 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
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 3 3 6.000000 $333.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 16 16 32.000000 $2400.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 203 204 426.000000 $31950.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 24 24 48.000000 $3600.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 75 77 154.000000 $11550.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 11 11 22.000000 $1650.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 38 38 94.000000 $7050.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 30 31 61.000000 $3385.5000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 57 59 118.000000 $6549.0000 $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 34 37 9.359527 $477.8200 $51.0500
OCTF -97168GT OT RE-EVAL EST PLAN CARE 3 3 0.683333 $34.8800 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 3 3 2.483333 $126.7700 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 37 37 18.461110 $942.4300 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 16 16 3.403968 $173.7700 $51.0500
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.0500 $51.0500
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 0.033333 $1.7000 $51.0000
PSTH -97163 PT EVAL HIGH COMPLEXITY 20 21 12.366667 $631.3200 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 3 3 2.394444 $122.2300 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 78 80 37.356347 $1907.0200 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 7 7 3.588888 $183.2100 $51.0500
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.438889 $22.4100 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 4 5 2.016666 $102.9500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 0.572222 $25.4900 $44.5500
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.100000 $4.4600 $44.5500
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Subtotal (Total Children Is Unduplicated) 437 763 1188.103866 $80669.3800 $67.9000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.000000 $10000.0000 $5000.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.811111 $186.5500 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 4 2.300000 $115.0000 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 3 5 4.000000 $200.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 4 0.766668 $19.1700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 128 134 89.961113 $4498.0700 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 0.200000 $10.0000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 109 117 116.722216 $2918.0400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 62 103 63.326187 $3166.3000 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 1 1 0.238889 $11.9500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 37 61 58.179370 $1454.5000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 17 32 13.011115 $650.5800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 16 30 26.783334 $669.5900 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 108 114 76.344446 $3817.2300 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 0.688889 $34.4500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 101 108 101.666663 $2541.6600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 148 159 1142.085714 $57104.2900 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 5 5 34.571429 $1728.5700 $50.0000
INTR -T1013 INTERPRETER 2 3 6.285714 $314.2900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 52 56 392.828572 $28063.6600 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 5 5 28.285714 $2020.7300 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 41 43 314.242858 $17974.6800 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 4 4 22.428572 $1282.9100 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 17 17 114.428572 $8174.7600 $71.4400
PHY -97110HM PT SESSION BY PT ASST 22 23 161.964286 $9257.8700 $57.1600
SENS -V5264 EARMOLD 1 1 1.622222 $29.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 86 93 695.928573 $49717.1200 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 10.428571 $745.0100 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 10 10 70.142857 $5011.0200 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 3 4 16.714286 $1194.0700 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 11.000000 $152.6800 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 1 1 4.000000 $148.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 304 1146 3583.957941 $213211.9200 $59.4900
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Total 1962 7446.937998 $391043.3000 $52.5100
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Number of Children (Unduplicated) With at Least One Authorization 588