Summary Report for FSPSAs Initiated During the Report Period Center: 54
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 1242 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 7 7 22.880953 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 5.857143 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 8 8 28.738096 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 27 29 49.124602 $2382.5400 $48.5000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 2 2 3.000000 $254.5200 $84.8400
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.000000 $22.4000 $22.4000
EXIT -EXIT EXIT ASSESSMENT 19 19 32.011112 $1600.5600 $50.0000
VISF -92499 VISION EVALUATION FUNCTIONAL 1 1 0.944444 $47.2200 $50.0000
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Subtotal (Total Children Is Unduplicated) 46 52 86.080158 $4307.2400 $50.0400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 7 9.888889 $49444.5000 $5000.0100
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.466667 $107.3400 $230.0200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 93 105 88.297221 $4414.8600 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 5 5 4.666667 $233.3400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 5 5 6.500000 $162.5000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 49 61 54.244443 $2712.2200 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 4 5 8.394444 $419.7200 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 70 70 65.135716 $3256.8000 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 6 7 3.411110 $170.5500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.988889 $24.7200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 48 48 39.028569 $1951.4200 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 3 3 0.994444 $49.7200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 121 123 116.621428 $5831.0800 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 8 8 5.522222 $276.1100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.844444 $21.1100 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 0.238889 $11.9500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 7 7 51.887302 $2594.3700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 378 718 2497.935703 $24979.3500 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 5.444444 $388.9500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 1 1 12.000000 $857.2800 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 3 14.933333 $1066.8400 $71.4400
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 1 1 0.571429 $21.1400 $37.0000
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Subtotal (Total Children Is Unduplicated) 388 1182 2988.016253 $98995.8400 $33.1300
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Total 1242 3102.834507 $103303.0800 $33.2900
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Number of Children (Unduplicated) With at Least One Authorization 403