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: 10-01-20 and 12-31-20 Date of Report: 01-23-21 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 513 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 9 9 7.222223 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 9 9 7.222223 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 0.083333 $4.0400 $48.4800
AUD -92626 EVAL OF AUD REHAB STATUS 3 3 2.072222 $117.0600 $56.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 4 4 1.383334 $19.1900 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 15 16 4.627778 $109.6800 $23.7000
EXIT -EXIT EXIT ASSESSMENT 1 1 2.000000 $100.0000 $50.0000
SCREEN-T1023 SCREENING 1 1 2.366667 $118.3400 $50.0000
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Subtotal (Total Children Is Unduplicated) 25 26 12.533334 $468.3000 $37.3600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 1.233333 $6166.5000 $4999.8700
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.833333 $41.6700 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.000000 $71.6100 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.433333 $99.6600 $229.9800
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 4 7 7.250000 $362.5000 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 9 10 7.071428 $353.5800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 2 2 1.333333 $66.6700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 2 4.285714 $107.1400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 9 9 4.080158 $204.0100 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 19 19 19.455556 $972.7800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 3 2.616666 $65.4200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 7 7 10.466667 $523.3400 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 11 11 12.422223 $621.1200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 15 15 13.077779 $653.9000 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 19 19 19.138889 $956.9500 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 12.000000 $300.0000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 3 2.050000 $102.5000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 80 84 365.577773 $18278.8600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 138 144 645.566669 $32278.3700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 36 41 131.603967 $1316.0400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 13 14 75.266663 $5377.0500 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 6 6 31.085714 $2220.7700 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 22 23 64.430951 $4602.9600 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 7 7 19.126190 $1366.3800 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 6 6 27.944444 $1996.3500 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 11 11 36.590476 $2614.0300 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 7 7 42.723810 $3052.1900 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 6 6 34.695238 $2478.6400 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 13 13 53.242857 $3803.6700 $71.4400
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Subtotal (Total Children Is Unduplicated) 312 478 1647.603164 $91079.6000 $55.2800
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Total 513 1667.358721 $91547.9000 $54.9100
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Number of Children (Unduplicated) With at Least One Authorization 318