Summary Report for FSPSAs Initiated During the Report Period Center: 05
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: 01-01-20 and 03-31-20 Date of Report: 05-15-20 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 693 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 6 6 6.199999 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 6 6 6.199999 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 9 9 12.000000 $600.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 3 1.010958 $75.8300 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 2 2 2.175342 $163.1500 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 3 2.005480 $150.4100 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 9 9 4.267124 $236.8200 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 3 3 0.012329 $0.9200 $74.8200
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 2 2 0.006850 $0.5100 $74.4500
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 8 8 0.042463 $2.3600 $55.6700
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.060274 $3.0800 $51.0700
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Subtotal (Total Children Is Unduplicated) 34 41 23.580820 $1383.0700 $58.6500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.000000 $10000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 16 16 9.371855 $468.6000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 202 215 237.059123 $11852.9300 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 11 11 3.923809 $196.1900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 2.766667 $69.1700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 64 65 65.051982 $3252.6000 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 2 2 0.919047 $45.9500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.966667 $74.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 79 82 88.051186 $4402.5400 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 4 4 1.622222 $81.1100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 150 162 161.210315 $8060.5000 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 5 5 0.816666 $40.8300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 4.705555 $117.6400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 19 21 114.142856 $5707.1500 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 5 5 8.785715 $439.2900 $50.0000
INTR -T1013 INTERPRETER 3 3 11.185715 $559.2900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 3 6.000000 $428.6400 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 2.285714 $163.2900 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 1 1 2.142857 $153.0900 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 6 6 31.285714 $2235.0500 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 1.285714 $91.8500 $71.4400
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 31 35 27.390477 $1013.4500 $37.0000
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Subtotal (Total Children Is Unduplicated) 284 646 784.969856 $49453.3000 $63.0000
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Total 693 814.750675 $50836.3700 $62.4000
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Number of Children (Unduplicated) With at Least One Authorization 301