Summary Report for FSPSAs Initiated During the Report Period Center: 55
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 706 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 18 18 481.322221 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 18 18 481.322221 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 26 28 26.563622 $1328.1800 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 1 2 4.000000 $200.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 39 41 70.142857 $3507.1500 $50.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 5 5 10.000000 $750.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.161111 $8.2200 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 0.172222 $8.7900 $51.0400
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.172222 $8.7900 $51.0400
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Subtotal (Total Children Is Unduplicated) 73 84 121.212034 $6522.1300 $53.8100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.733333 $36.6700 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.655556 $32.7800 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 1.000000 $50.0000 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 3 5 4.000000 $200.0000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 99 104 65.222219 $3261.1000 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 2 2 0.822222 $41.1100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 98 101 102.599998 $2565.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 49 87 42.033334 $2101.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 27 46 27.438888 $685.9700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 22 41 23.122224 $1156.1200 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 15 27 34.100002 $852.5100 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 82 84 57.733326 $2886.6300 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 0.172222 $8.6100 $49.9900
CONSP -CONSP CONSULT, SLP, PHONE 92 95 87.688886 $2192.2200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1 1 6.000000 $300.0000 $50.0000
INTR -T1013 INTERPRETER 1 2 4.000000 $200.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 10.428571 $745.0200 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 3 18.857142 $1347.1500 $71.4400
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Subtotal (Total Children Is Unduplicated) 182 604 487.607923 $23662.5400 $48.5300
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Total 706 1090.142178 $30184.6600 $27.6900
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Number of Children (Unduplicated) With at Least One Authorization 249