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: 01-01-21 and 03-31-21 Date of Report: 05-04-21 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 457 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 10 11 8.277777 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 10 11 8.277777 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 2 2.000000 $97.0000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $56.4900 $56.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 5 5 1.883334 $26.1200 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 23 23 11.466668 $271.7600 $23.7000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 31 31 16.350002 $451.3800 $27.6100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 5 4.533333 $22666.5000 $4999.9600
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.266667 $19.1000 $71.6200
AUDE -V5160 DISPENSING FEE BINAURAL 6 6 3.683333 $847.1600 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 7 9 6.005556 $300.2800 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 10 11 7.142857 $357.1500 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 5 5 6.760318 $338.0200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.933333 $48.3300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 7 7 7.444445 $372.2300 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 23 23 44.245236 $2212.2600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 4 4 15.849999 $396.2500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 3 3 1.750000 $87.5000 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 10 10 11.677777 $583.8900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 11.000000 $275.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 11 11 9.722223 $486.1200 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 12 12 13.077778 $653.8900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 2.333333 $58.3300 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 1.000000 $73.3200 $73.3200
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 49 51 202.609525 $10130.4700 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 148 153 734.261910 $36713.0700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 16 19 55.556349 $555.5600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 8 8 18.269842 $1305.2000 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 8.257143 $589.8900 $71.4400
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 1.285714 $91.8500 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 25 26 124.111112 $8866.5000 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 4 4 4.820635 $344.3900 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 2 2 8.571429 $612.3400 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 10 10 57.019048 $4073.4300 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 10 10 45.265873 $3233.8000 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 7 7 19.304762 $1379.1300 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 7 7 66.038096 $4717.7600 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 2.283333 $31.6900 $13.8800
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 274 415 1496.080959 $102420.3700 $68.4600
-------------------------------------------------------------------------------------------------------------------------------------
Total 457 1520.708738 $102871.7500 $67.6500
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 283