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 838 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 27 27 48.733334 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 91.000000 $3367.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 28 28 139.733334 $3367.0000 $24.1000
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 35 36 66.142857 $3307.1500 $50.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 5 5 10.000000 $750.0000 $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 2 2 4.000000 $300.0000 $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 1 1 2.000000 $111.0000 $55.5000
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 0.227778 $11.6300 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 0.138889 $7.0900 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.172222 $59.8400 $51.0500
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Subtotal (Total Children Is Unduplicated) 67 78 121.384028 $6532.8700 $53.8200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.000000 $10000.0000 $5000.0000
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 2 2 27.428571 $1371.4300 $50.0000
INTR -T1013 INTERPRETER 2 3 6.285714 $314.2900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 2.285714 $163.2900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 2 2 17.571429 $1005.0800 $57.2000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 5 5 39.571429 $2826.9700 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 2.285714 $163.2900 $71.4400
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 1 1 4.000000 $148.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 203 732 655.617461 $36098.8600 $55.0600
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Total 838 916.734823 $45998.7200 $50.1800
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Number of Children (Unduplicated) With at Least One Authorization 258