Summary Report for FSPSAs Initiated During the Report Period Center: 04
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: 04-01-20 and 06-30-20 Date of Report: 07-20-20 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 508 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 29 32 16.488889 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 29 32 16.488889 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 3 3 0.472223 $22.9100 $48.5100
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 0.422222 $21.5500 $51.0500
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Subtotal (Total Children Is Unduplicated) 4 4 0.894445 $44.4600 $49.7100
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 7 18 5.249996 $262.4800 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 3 4 2.400000 $120.0000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 2 3 1.388889 $69.4500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 1.011111 $50.5600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.000000 $25.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 20 20 135.285714 $6764.2800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 375 408 2667.246040 $26672.4600 $10.0000
PHY -97110 PT SESSION BY LICENSED PT 2 2 17.142857 $1224.6800 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 8.571429 $490.2800 $57.2000
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 10 14 50.178571 $1856.6200 $37.0000
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Subtotal (Total Children Is Unduplicated) 389 472 2889.474607 $37535.8000 $12.9900
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Total 508 2906.857941 $37580.2600 $12.9300
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Number of Children (Unduplicated) With at Least One Authorization 412