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: 01-01-23 and 03-31-23 Date of Report: 04-20-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 697 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 32 34 52.298414 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 32 34 52.298414 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 1 1 0.500000 $37.5000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 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
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 3 3 6.000000 $450.0000 $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 8 8 16.000000 $1200.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 4.000000 $222.0000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 4.000000 $222.0000 $55.5000
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
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Subtotal (Total Children Is Unduplicated) 16 23 42.500000 $2906.3200 $68.3800
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 23 24 31.961905 $1598.1000 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 13 16 24.328571 $1216.4300 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 6 6 6.000000 $150.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 153 162 177.022220 $8851.1000 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 41 43 48.609522 $2430.4700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 0.011111 $0.2800 $24.9800
CONOF -CONOF CONSULT, OT, FACE TO FACE 62 64 77.875396 $3893.7700 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 31 33 42.116667 $2105.8400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.988889 $24.7200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 56 65 58.934133 $2946.7400 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 32 39 32.348414 $1617.4300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 109 118 129.316273 $6465.8300 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 43 44 60.257143 $3012.8600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 1.900000 $47.5000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 10.428571 $521.4300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 5 7 26.571428 $1328.5700 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 2.428571 $121.4300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3 4 15.428571 $154.2900 $10.0000
PHY -97110 PT SESSION BY LICENSED PT 2 2 9.071429 $652.7800 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 1 1 4.000000 $287.8400 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 2 7.000000 $503.7200 $71.9600
TRAV -TRAVS Travel by mile 3 4 62.428571 $27.7800 $0.4400
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Subtotal (Total Children Is Unduplicated) 222 640 829.027385 $37958.8800 $45.7900
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Total 697 923.825799 $40865.2000 $44.2300
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Number of Children (Unduplicated) With at Least One Authorization 261