Summary Report for FSPSAs Initiated During the Report Period Center: 02
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: 10-01-21 and 12-31-21 Date of Report: 02-04-22 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1157 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 1 1 0.084932 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 0.084932 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 16 18 14.928081 $724.0100 $48.5000
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 0.494444 $24.7200 $50.0000
EXIT -EXIT EXIT ASSESSMENT 27 27 26.473972 $1323.7100 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.0500 $51.0500
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Subtotal (Total Children Is Unduplicated) 45 48 43.896497 $2174.5300 $49.5400
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 2.166667 $108.3400 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 32 32 28.872223 $1443.6200 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 4 5 7.000000 $350.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 4 4 2.755556 $68.8900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 160 177 380.080955 $19004.0600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.800000 $45.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 85 87 179.761906 $8988.1000 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 3 3 6.133334 $306.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.733333 $18.3300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 15 15 46.871428 $2343.5700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 2.533333 $63.3300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 136 144 259.123811 $12956.2000 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 5 5 5.666667 $283.3400 $50.0000
INTR -T1013 INTERPRETER 14 22 71.912393 $3595.6200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 162 284 1439.952368 $14399.5400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 9.285714 $663.3700 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 1.000000 $71.4400 $71.4400
TRAV -TRAVS Travel by mile 169 323 76786.164792 $34169.8400 $0.4500
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Subtotal (Total Children Is Unduplicated) 203 1108 79231.814480 $98879.2300 $1.2500
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Total 1157 79275.795909 $101053.7600 $1.2700
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Number of Children (Unduplicated) With at Least One Authorization 215