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
Eligibility Filter: Program Patients
With the filters selected there were 1174 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 11.555555 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 9 9 11.555555 $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 10 10 16.872223 $1265.4200 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 4 4 6.005479 $450.4100 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 2 2 3.000000 $225.0000 $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 26 26 44.743227 $2483.2500 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 4 4 3.008219 $166.9600 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 18 18 35.000000 $2625.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 27 27 50.106849 $3758.0100 $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 7 7 9.505479 $712.9100 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 35 35 63.109589 $4733.2100 $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 21 21 39.002740 $2164.6500 $55.5000
OCTH -97167 OT EVAL HIGH COMPLEXITY 4 4 13.197260 $673.7200 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.139726 $7.1300 $51.0400
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Subtotal (Total Children Is Unduplicated) 116 209 375.196270 $25085.2400 $66.8600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 25 29 25.169082 $1258.4700 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 24 28 31.409524 $1570.4800 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 261 273 319.272471 $15963.6800 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 44 45 46.641274 $2332.0800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 89 91 106.390477 $5319.5300 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 13 14 24.881745 $1244.0900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 3 4.884127 $122.1100 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 88 90 104.305006 $5215.2800 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 22 22 23.696826 $1184.8500 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.516667 $12.9200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 196 201 228.086515 $11404.3700 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 38 39 48.745240 $2437.2800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 4 2.633333 $65.8300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 77 81 553.490468 $27674.5500 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 22 22 147.899998 $7395.0100 $50.0000
INTR -T1013 INTERPRETER 1 1 7.428571 $371.4300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 8.142857 $581.7300 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 1 1 2.000000 $142.8800 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 5 5 36.999999 $2643.2800 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 6.000000 $428.6400 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 6.428571 $459.2600 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 6.428571 $459.2600 $71.4400
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Subtotal (Total Children Is Unduplicated) 324 956 1742.451322 $93286.9700 $53.5400
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Total 1174 2129.203147 $118372.2000 $55.5900
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Number of Children (Unduplicated) With at Least One Authorization 392