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: 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 534 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 7 7 11.411111 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 7 7 11.411111 $0.0000 $0.0000
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 3 3 3.000000 $169.4700 $56.4900
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.000000 $23.4900 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 3 0.611111 $8.4800 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 21 21 10.627777 $251.8800 $23.7000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.238889 $20.2700 $84.8400
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Subtotal (Total Children Is Unduplicated) 30 30 16.477777 $522.0800 $31.6800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 10.428571 $52143.0000 $5000.0100
AUDE -V5160 DISPENSING FEE BINAURAL 4 4 2.516667 $578.8400 $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 -CONIF CONSULT, ITDS FACE TO FACE 2 2 0.583333 $29.1700 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 7 7 10.983335 $549.1800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.933333 $48.3300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 11 12 13.050000 $652.5000 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 29 29 23.388890 $1169.4500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 4 4 5.566667 $139.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 4 4 2.655556 $132.7800 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 7 7 20.092857 $1004.6500 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.000000 $25.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 10 10 4.944446 $247.2300 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 13 14 10.083335 $504.1800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 1.977778 $49.4500 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 69 72 292.463088 $14623.1500 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 164 178 805.368243 $40268.4100 $50.0000
INTR -T1013 INTERPRETER 1 1 0.700000 $35.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 22 26 73.635714 $736.3600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 11 12 37.885714 $2706.5500 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 5 5 29.942857 $2139.1100 $71.4400
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 11.285714 $806.2500 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 26 27 88.877777 $6349.4400 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 2 2 7.866667 $562.0000 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 20 20 76.233331 $5446.1000 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 4 5 8.263491 $590.3400 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 8 8 47.428572 $3388.3000 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 1.400000 $100.0200 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 18 18 65.661904 $4690.9000 $71.4400
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Subtotal (Total Children Is Unduplicated) 330 497 1669.366253 $140372.2500 $84.0900
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Total 534 1697.255141 $140894.3300 $83.0100
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Number of Children (Unduplicated) With at Least One Authorization 338