Summary Report for FSPSAs Initiated During the Report Period Center: 53
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: 07-01-21 and 09-30-21 Date of Report: 10-13-21 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 139 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 3 3 3.800001 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 3 3 3.800001 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 6 7 7.000000 $339.5000 $48.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 6 7 7.000000 $339.5000 $48.5000
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 6 9 8.250000 $412.5000 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 4 5 3.250000 $162.5000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 3 3 2.022222 $101.1100 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 3 3 9.792858 $489.6400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 5 5 3.477777 $173.8900 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 21 23 24.192063 $1209.5900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 4 4 5.900000 $147.5000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 1.000000 $50.0000 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 8 8 9.066666 $453.3300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 6 6 8.416666 $420.8300 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 11 11 9.711110 $485.5500 $50.0000
INTR -T1013 INTERPRETER 1 1 6.142857 $307.1500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 39 48 208.436507 $2084.3600 $10.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 9.200000 $657.2500 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 3.066667 $219.0900 $71.4400
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 86 129 311.925393 $7374.2800 $23.6400
-------------------------------------------------------------------------------------------------------------------------------------
Total 139 322.725394 $7713.7800 $23.9000
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 90