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: 07-01-20 and 09-30-20 Date of Report: 10-15-20 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 776 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 6 6 6.572222 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 6 6 6.572222 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 5 5 4.394444 $213.1300 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 15 15 7.311112 $173.2800 $23.7000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.455556 $20.5000 $45.0000
SCREEN-T1023 SCREENING 1 1 0.255556 $12.7800 $50.0100
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Subtotal (Total Children Is Unduplicated) 22 22 12.416668 $419.6900 $33.8000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 4.000000 $20000.0000 $5000.0000
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 2.000000 $460.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 4 4 5.000000 $250.0000 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 5 5 4.285714 $214.2900 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 4 4 13.295237 $664.7600 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 1.000000 $50.0000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 33 33 38.383332 $1919.1600 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 16 16 21.378572 $1068.9400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 8 8 9.066667 $453.3400 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 4 4 6.200000 $310.0000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 17 17 40.149207 $2007.4600 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 10 10 8.538889 $426.9500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 3.633333 $90.8300 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 4 20.695237 $1034.7600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 181 184 773.303172 $38665.1700 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 69 80 351.066669 $17553.3400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 218 260 935.807138 $9358.0800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 22 22 102.742857 $7339.9700 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 5.133333 $366.7200 $71.4400
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 4.142857 $236.9700 $57.2000
OCCT -97530TL OT SESSION BY LICENSED OT 2 2 5.857142 $418.4400 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 14 15 74.257142 $5304.9300 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 20 20 115.890475 $8279.2300 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 4 4 34.428571 $2459.5800 $71.4400
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 1 1 5.466667 $312.4800 $57.1600
PHY -97110TLGT PT SESSION BY LICENSED PT 8 9 42.523808 $3037.9000 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 15 15 89.080952 $6363.9600 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 6 6 45.619047 $3259.0200 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 14 14 82.223810 $5874.0600 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 2.866667 $39.7900 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 1 1 7.142857 $264.2900 $37.0000
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Subtotal (Total Children Is Unduplicated) 337 748 2855.179352 $138084.4000 $48.3600
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Total 776 2874.168242 $138504.0900 $48.1900
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Number of Children (Unduplicated) With at Least One Authorization 345