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: 10-01-22 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 524 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 27 27 36.817459 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 27 27 36.817459 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 1 1 2.000000 $100.0000 $50.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $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
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $150.0000 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.600000 $30.8500 $51.4100
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Subtotal (Total Children Is Unduplicated) 4 6 10.600000 $691.8500 $65.2700
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 20 22 29.341269 $1467.0600 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 15 16 24.596825 $1229.8400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 2.000000 $50.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 140 148 198.032540 $9901.6300 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 38 39 50.392857 $2519.6400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 45 45 64.432542 $3221.6400 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 20 21 23.933333 $1196.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.855556 $21.3900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 39 42 39.123809 $1956.1900 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 16 17 15.222222 $761.1100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 83 87 121.955553 $6097.7700 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 44 44 69.699205 $3484.9600 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 20.857143 $1042.8600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 2 2 18.000000 $900.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2 2 5.714286 $57.1400 $10.0000
TRAV -TRAVS Travel by mile 1 1 45.000000 $20.0300 $0.4500
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Subtotal (Total Children Is Unduplicated) 182 491 729.157140 $33927.9000 $46.5300
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Total 524 776.574599 $34619.7500 $44.5800
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Number of Children (Unduplicated) With at Least One Authorization 208