Summary Report for FSPSAs Ending During the Report Period Center: 53
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: 10-01-20 and 12-31-20 Date of Report: 01-23-21 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 169 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 9 9 7.222223 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 9 9 7.222223 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 0.083333 $4.0400 $48.4800
EXIT -EXIT EXIT ASSESSMENT 1 1 2.000000 $100.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 2 2 2.083333 $104.0400 $49.9400
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.833333 $41.6700 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 4 7 7.250000 $362.5000 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 9 10 7.071428 $353.5800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 2 2 1.333333 $66.6700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 2 4.285714 $107.1400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 9 9 4.080158 $204.0100 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 19 19 19.455556 $972.7800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 3 2.616666 $65.4200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 7 7 10.466667 $523.3400 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 11 11 12.422223 $621.1200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 15 15 13.077779 $653.9000 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 19 19 19.138889 $956.9500 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 3 2.050000 $102.5000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 2 2 2.600000 $130.0000 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 5 6 18.657143 $932.8600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 36 41 131.603967 $1316.0400 $10.0000
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Subtotal (Total Children Is Unduplicated) 114 158 257.942856 $7435.4300 $28.8300
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Total 169 267.248412 $7539.4700 $28.2100
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Number of Children (Unduplicated) With at Least One Authorization 122