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
Eligibility Filter: Program Patients
With the filters selected there were 1287 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 17 17 19.038095 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 17 17 19.038095 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
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 8 8 13.005556 $975.4200 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 4 4 6.005479 $450.4100 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 1.000000 $75.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 2 2 3.000000 $225.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 47 47 77.323211 $4291.4400 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 8 8 6.577626 $365.0600 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 17 17 34.000000 $2550.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 26 26 50.000000 $3750.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 14 14 27.000000 $2025.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 8 8 10.505479 $787.9100 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 34 34 63.002740 $4725.2000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 30 30 53.505479 $2969.5600 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 20 20 37.002740 $2053.6500 $55.5000
OCTH -97167 OT EVAL HIGH COMPLEXITY 3 3 1.375342 $70.2100 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 1.038889 $53.0400 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.024658 $1.2600 $51.1400
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 137 231 396.367199 $26268.1500 $66.2700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 0.227397 $1137.0000 $5000.0700
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 24 27 26.559557 $1327.9800 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 26 30 23.783333 $1189.1700 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 257 270 309.688092 $15484.3900 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 36 37 30.425399 $1521.2800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 86 91 112.446028 $5622.2800 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 16 16 18.647618 $932.3700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 3 5.661904 $141.5500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 110 113 102.309524 $5115.4800 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 29 29 27.435714 $1371.7900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 210 220 230.055148 $11502.7100 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 33 34 54.317460 $2715.8800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 1.566667 $39.1700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 85 89 469.714286 $23485.7400 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 44 46 255.985714 $12799.2900 $50.0000
INTR -T1013 INTERPRETER 1 1 5.714286 $285.7200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 5 5 39.285714 $2806.5800 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 8.714286 $622.5500 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 2.714286 $155.1500 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 4 4 27.571428 $1969.7100 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 10.428572 $745.0200 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 10.857143 $150.7000 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 14 15 26.395239 $976.6300 $37.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 339 1039 1800.504795 $92098.0900 $51.1500
-------------------------------------------------------------------------------------------------------------------------------------
Total 1287 2215.910089 $118366.2400 $53.4200
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 444