Summary Report for FSPSAs Ending During the Report Period Center: 05
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 625 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 12 12 12.415873 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 12 12 12.415873 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 1 1 0.005479 $0.4100 $75.2900
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 5 5 5.418645 $300.7300 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 2 2 1.002740 $55.6500 $55.5000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 1 1 0.500000 $37.5000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 2.500000 $138.7500 $55.5000
OCTH -97167 OT EVAL HIGH COMPLEXITY 2 2 1.167123 $59.5800 $51.0500
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Subtotal (Total Children Is Unduplicated) 9 14 12.593987 $742.6300 $58.9700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.027397 $137.0000 $5000.5500
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 18 20 16.738128 $836.9100 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 17 19 15.833333 $791.6700 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 166 177 216.759920 $10837.9900 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 26 27 23.519844 $1176.0100 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 53 57 74.142856 $3707.1300 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 10 10 14.996031 $749.8000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 3 5.661904 $141.5500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 75 77 70.011110 $3500.5500 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 21 21 23.641271 $1182.0700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 129 137 154.584916 $7729.2300 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 20 21 25.395236 $1269.7600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 1.566667 $39.1700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 8 8 60.857143 $3042.8700 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 4 4 38.571428 $1928.5800 $50.0000
INTR -T1013 INTERPRETER 1 1 5.714286 $285.7200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 28.428571 $2030.9400 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 8.714286 $622.5500 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 12.000000 $857.2800 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 8.714286 $622.5500 $71.4400
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 8 9 12.857144 $475.7200 $37.0000
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Subtotal (Total Children Is Unduplicated) 216 599 818.735757 $41964.9900 $51.2600
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Total 625 843.745617 $42707.6200 $50.6200
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Number of Children (Unduplicated) With at Least One Authorization 230