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: 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 496 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 10.666666 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 3 3 4.933333 $182.5300 $37.0000
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Subtotal (Total Children Is Unduplicated) 11 11 15.599999 $182.5300 $11.7000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 1.000000 $48.5000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 7 8 5.494444 $310.3800 $56.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 5 5 1.288890 $17.8800 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 10 10 4.805555 $113.8900 $23.7000
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Subtotal (Total Children Is Unduplicated) 23 24 12.588889 $490.6500 $38.9700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 2 2.000000 $10000.0000 $5000.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.294444 $21.0800 $71.6000
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 2.311111 $531.5500 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 4 4.250000 $212.5000 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 8 9 6.071428 $303.5800 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 3 3 4.349206 $217.4600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 12 12 19.624602 $981.2300 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 26 27 37.555552 $1877.7600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 3 7.833333 $195.8300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 0.794445 $39.7300 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 12 12 17.355553 $867.7700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 5.400000 $135.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 11 11 12.050001 $602.5100 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 10 10 12.572222 $628.6100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 1.200000 $30.0000 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 1.000000 $73.3200 $73.3200
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 68 68 339.807139 $16990.3600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 168 175 856.011897 $42800.6400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 18 20 78.566666 $785.6700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 5 6 17.895239 $1278.4500 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 5 5 27.609522 $1972.4200 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 26 29 135.571425 $9685.2400 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 6 6 37.389683 $2671.1100 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 4 5 21.934920 $1567.0300 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 15 15 103.090473 $7364.7800 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 4 4 14.782539 $1056.0700 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 6 6 19.795238 $1414.1600 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 18 18 132.922222 $9495.9800 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 0.450000 $6.2500 $13.8800
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Subtotal (Total Children Is Unduplicated) 323 461 1920.488860 $113806.0400 $59.2600
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Total 496 1948.677748 $114479.2200 $58.7500
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Number of Children (Unduplicated) With at Least One Authorization 331