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: 10-01-22 and 12-31-22 Date of Report: 01-23-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 531 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 24 24 20.311108 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 24 24 20.311108 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 1 1 2.000000 $100.0000 $50.0000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $150.0000 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 1.000000 $50.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 3 4 7.000000 $411.0000 $58.7100
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 17 22 13.283332 $664.1600 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 14 15 12.061111 $603.0600 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 2.000000 $50.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 143 153 173.449601 $8672.4700 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 43 44 60.885713 $3044.2800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 46 49 52.457146 $2622.8700 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 6 6 7.188889 $359.4500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 43 48 48.784921 $2439.2500 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 14 15 16.166667 $808.3400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.466667 $61.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 100 102 121.493646 $6074.6600 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 38 38 48.159524 $2407.9800 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 19.571429 $978.5700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 3 3 13.000000 $650.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2 2 9.428571 $94.2900 $10.0000
TRAV -TRAVS Travel by mile 1 1 45.000000 $20.0300 $0.4500
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Subtotal (Total Children Is Unduplicated) 186 503 645.397217 $29551.0500 $45.7900
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Total 531 672.708325 $29962.0500 $44.5400
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Number of Children (Unduplicated) With at Least One Authorization 206