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: 04-01-20 and 06-30-20 Date of Report: 07-20-20 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 585 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 9 9 9.811113 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 9 9 9.811113 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 2 2.000000 $97.0000 $48.5000
EXIT -EXIT EXIT ASSESSMENT 1 1 2.000000 $100.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 8 8 12.241096 $679.3800 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 5 5 3.013698 $167.2600 $55.5000
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 0.194521 $9.9300 $51.0400
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Subtotal (Total Children Is Unduplicated) 14 18 21.449315 $1203.5700 $56.1100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.134247 $671.0000 $4998.2500
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 7 7 5.005480 $250.2700 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 13 14 11.321102 $566.0600 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 151 156 263.054763 $13152.7400 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 22 25 17.912700 $895.6400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 51 53 57.446032 $2872.3100 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 12 13 11.166666 $558.3300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 10.714286 $267.8600 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 71 73 59.944441 $2997.2100 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 13 14 11.033332 $551.6600 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.016667 $0.4200 $25.0500
CONSF -CONSF CONSULT, SLP, FACE TO FACE 108 111 113.590479 $5679.5400 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 23 23 28.847619 $1442.3800 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 17 18 85.071429 $4253.5700 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 14 14 87.857142 $4392.8700 $50.0000
INTR -T1013 INTERPRETER 2 2 13.000000 $650.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 3 3 11.928571 $852.1700 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 10.142857 $724.6100 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 1 1 4.071429 $290.8600 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 1.142857 $81.6500 $71.4400
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 24 26 99.436901 $3679.1700 $37.0000
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Subtotal (Total Children Is Unduplicated) 216 558 902.839000 $44830.2900 $49.6500
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Total 585 934.099428 $46033.8600 $49.2800
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Number of Children (Unduplicated) With at Least One Authorization 232