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: 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 517 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 8 8 9.533333 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 8 8 9.533333 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 2 2.000000 $97.0000 $48.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 4 4 0.672222 $9.3200 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 27 27 14.194443 $336.4100 $23.7000
EXIT -EXIT EXIT ASSESSMENT 1 1 2.000000 $100.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 34 34 18.866665 $542.7300 $28.7700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 5 6.000000 $30000.0000 $5000.0000
AUDE -V5160 DISPENSING FEE BINAURAL 5 5 2.816667 $647.8400 $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 6 6 5.285714 $264.2900 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 6 7 10.678571 $533.9300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.000000 $25.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 5 5 6.916667 $345.8400 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 26 27 22.239684 $1112.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 1.433333 $35.8300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 3 3 3.516666 $175.8300 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 11 12 16.205556 $810.2800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 11 12 8.911110 $445.5500 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 18 18 20.638095 $1031.9000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 1.500000 $37.5000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 9.714285 $242.8600 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 3 7.400000 $370.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 65 67 347.336108 $17366.8000 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 164 174 751.435708 $37571.7800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 19 22 101.922222 $1019.2200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 7 7 35.952381 $2568.4400 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 3 3 5.352381 $382.3800 $71.4400
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 12.000000 $857.2800 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 33 35 161.949999 $11569.7000 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 5 5 47.942858 $3425.0300 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 2.866667 $204.8000 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 16 17 56.566665 $4041.1200 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 8 8 27.466666 $1962.2100 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 6 6 54.914286 $3923.0800 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 10 10 24.114286 $1722.7300 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 6.916666 $96.0000 $13.8800
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Subtotal (Total Children Is Unduplicated) 329 475 1765.993241 $123039.2000 $69.6700
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Total 517 1794.393239 $123581.9300 $68.8700
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Number of Children (Unduplicated) With at Least One Authorization 336