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: 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 566 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 6.955556 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 6 6 6.955556 $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 2 2 2.455556 $136.2900 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 1 1 0.002740 $0.1500 $54.6700
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 1 1 11.000000 $561.5500 $51.0500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 6 9 18.463775 $1024.6500 $55.5000
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 17 20 16.452415 $822.6300 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 15 17 14.416667 $720.8400 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 178 187 190.596834 $9529.8900 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 25 26 23.586510 $1179.3400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 45 47 49.414287 $2470.7200 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 7 8 15.311110 $765.5500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 3.428571 $85.7200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 56 58 61.611116 $3080.5800 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 17 17 19.807937 $990.4000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 132 136 147.269845 $7363.5100 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 23 24 26.181747 $1309.1000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 3 1.844444 $46.1100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 5 5 37.142856 $1857.1500 $50.0000
INTR -T1013 INTERPRETER 1 1 7.428571 $371.4300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 2.142857 $153.0900 $71.4400
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 208 551 616.635767 $30746.0300 $49.8600
-------------------------------------------------------------------------------------------------------------------------------------
Total 566 642.055098 $31770.6800 $49.4800
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 216