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: 10-01-21 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 516 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 7 7 9.757142 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 7 7 9.757142 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
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
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Subtotal (Total Children Is Unduplicated) 1 2 4.000000 $261.0000 $65.2500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.000000 $10000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 21 25 24.644445 $1232.2300 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 11 13 7.527777 $376.3900 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 159 166 201.864681 $10093.2200 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 16 16 19.446032 $972.3000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 74 75 94.720638 $4736.0500 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 4 4 3.755555 $187.7800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 46 47 56.641274 $2832.0900 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 8 8 10.655556 $532.7800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 122 124 136.255163 $6812.7800 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 23 24 31.512699 $1575.6400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 2 2 19.142857 $957.1500 $50.0000
INTR -T1013 INTERPRETER 1 1 2.000000 $100.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 209 507 610.166677 $40408.3800 $66.2300
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Total 516 623.923819 $40669.3800 $65.1800
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Number of Children (Unduplicated) With at Least One Authorization 217