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: 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 227 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 11 11 7.238888 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 11 11 7.238888 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 7 8 6.316666 $306.3600 $48.5000
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Subtotal (Total Children Is Unduplicated) 7 8 6.316666 $306.3600 $48.5000
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.433333 $99.6600 $229.9800
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 -CONIFGT CONSULT,ITDS,FACE TO FACE 2 2 1.033333 $51.6700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.000000 $25.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 12 12 8.849999 $442.5000 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 21 22 18.022223 $901.1200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 6 6 5.138890 $128.4800 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 12 12 18.927777 $946.3900 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 9 9 13.516667 $675.8400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 6 6 4.750000 $237.5000 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 13 13 16.377778 $818.8900 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 6.714285 $335.7200 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 11.142857 $557.1500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 90 103 311.998408 $3119.9900 $10.0000
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Subtotal (Total Children Is Unduplicated) 145 208 433.272217 $9108.2100 $21.0200
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Total 227 446.827771 $9414.5600 $21.0700
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Number of Children (Unduplicated) With at Least One Authorization 157