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: 01-01-22 and 03-31-22 Date of Report: 04-16-22 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 603 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 36 36 35.028574 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 36 36 35.028574 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 2 0.672222 $32.6000 $48.5000
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 0.716667 $36.5900 $51.0500
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Subtotal (Total Children Is Unduplicated) 4 4 1.388889 $69.1900 $49.8200
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 12 30 7.188892 $359.4600 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 5 6 2.777777 $138.8900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 0.711111 $17.7800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 4 1.622222 $81.1100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 1.355555 $33.8900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 0.511111 $25.5600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 0.466667 $23.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 1.577778 $39.4500 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 4 4 22.000000 $1100.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 5 6 49.571428 $2478.5800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 473 503 3360.699958 $33607.0300 $10.0000
PHY -97110 PT SESSION BY LICENSED PT 1 1 18.000000 $1285.9200 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 9.428571 $538.9400 $57.1600
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Subtotal (Total Children Is Unduplicated) 487 563 3475.911070 $39729.9100 $11.4300
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Total 603 3512.328533 $39799.1000 $11.3300
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Number of Children (Unduplicated) With at Least One Authorization 518