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: 10-01-21 and 12-31-21 Date of Report: 02-04-22 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 600 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 16 16 19.188889 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 16 16 19.188889 $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 -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
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
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 1 1 0.716667 $35.8400 $50.0000
OCTH -97167 OT EVAL HIGH COMPLEXITY 2 2 1.246575 $63.6400 $51.0500
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Subtotal (Total Children Is Unduplicated) 5 7 9.963242 $621.4700 $62.3800
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 19 22 21.933333 $1096.6700 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 10 11 8.000000 $400.0000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 160 172 207.253570 $10362.6600 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 31 31 45.324603 $2266.2300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 65 68 81.234127 $4061.7000 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 12 12 20.903176 $1045.1700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 61 63 65.632935 $3281.6400 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 16 17 19.666665 $983.3300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.033333 $25.8300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 124 132 140.085687 $7004.2900 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 37 39 47.666662 $2383.3100 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 6 6 58.857142 $2942.8600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 12.857143 $642.8600 $50.0000
INTR -T1013 INTERPRETER 1 1 2.000000 $100.0000 $50.0000
PHY -97110 PT SESSION BY LICENSED PT 1 1 2.000000 $142.8800 $71.4400
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Subtotal (Total Children Is Unduplicated) 216 577 734.448376 $36739.4000 $50.0200
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Total 600 763.600507 $37360.8800 $48.9300
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Number of Children (Unduplicated) With at Least One Authorization 232