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: 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 181 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 10 10 8.122222 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 10 10 8.122222 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 5 5 4.022222 $195.0800 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.405556 $9.5300 $23.5000
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Subtotal (Total Children Is Unduplicated) 6 6 4.427778 $204.6100 $46.2100
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 7 8 6.250000 $312.5000 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 8 10 9.116667 $455.8400 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1 1 1.666667 $83.3400 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 6 6 5.351588 $267.5800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 7 7 8.222223 $411.1200 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 23 23 39.592065 $1979.6100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 1.377778 $34.4500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 8 9 26.225397 $1311.2800 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 7 7 8.333334 $416.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 6 6 4.150001 $207.5100 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 8 9 9.327777 $466.3900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1 1 1.366667 $68.3400 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 2 7.263492 $363.1800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 64 73 300.782540 $3007.8200 $10.0000
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Subtotal (Total Children Is Unduplicated) 108 165 430.026196 $9615.5800 $22.3600
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Total 181 442.576196 $9820.1900 $22.1900
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Number of Children (Unduplicated) With at Least One Authorization 119