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: 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 721 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 22 22 26.246032 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 22 22 26.246032 $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 2 2 4.000000 $300.0000 $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 7 7 14.000000 $1050.0000 $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
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 0.227778 $11.7100 $51.4100
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 17 23 38.727778 $2618.0300 $67.6000
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 26 27 20.927779 $1046.4000 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 14 16 11.488888 $574.4400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 6 6 6.000000 $150.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 168 173 164.516666 $8225.8300 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 50 53 59.920634 $2996.0300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 0.011111 $0.2800 $24.9800
CONOF -CONOF CONSULT, OT, FACE TO FACE 66 68 60.406350 $3020.3200 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 44 44 38.606350 $1930.3200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 58 68 47.720629 $2386.0100 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 27 36 19.733329 $986.6500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 92 98 73.226978 $3661.3200 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 50 56 59.230953 $2961.5500 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 10.714286 $535.7200 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 7 10 39.785714 $1989.2900 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 4.428571 $221.4300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2 3 3.000000 $30.0000 $10.0000
PHY -97110 PT SESSION BY LICENSED PT 5 5 19.499999 $1403.2300 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 3 3 12.857142 $925.2000 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 3 11.428571 $822.4000 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 4.428571 $318.6800 $71.9600
TRAV -TRAVS Travel by mile 2 3 50.000000 $22.2500 $0.4500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 222 676 717.932521 $34207.3200 $47.6500
-------------------------------------------------------------------------------------------------------------------------------------
Total 721 782.906331 $36825.3500 $47.0400
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 246