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: 04-01-21 and 06-30-21 Date of Report: 07-15-21 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 555 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 6 6 4.305555 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 3 3 1.466667 $54.2700 $37.0000
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Subtotal (Total Children Is Unduplicated) 9 9 5.772222 $54.2700 $9.4000
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 6 6 4.338889 $245.1000 $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 0.805556 $11.1700 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 17 17 8.116667 $192.3700 $23.7000
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Subtotal (Total Children Is Unduplicated) 28 29 16.261112 $569.1300 $35.0000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 2 2.000000 $10000.0000 $5000.0000
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 2.166667 $498.3400 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 5 5 4.005556 $200.2800 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 10 10 9.500000 $475.0000 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 4 4 3.817460 $190.8800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.000000 $25.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 16 17 16.373809 $818.6900 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 27 29 38.466666 $1923.3300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 3 4.000000 $100.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 1.938889 $96.9500 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 11 11 16.255555 $812.7800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 10 12 14.188889 $709.4500 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 12 12 15.161111 $758.0600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 6 6 4.994445 $124.8600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 67 68 327.100001 $16354.9900 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 179 186 997.002384 $49850.0800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 29 33 122.870634 $1228.7000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 4 4 10.266666 $733.4500 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 3 3 13.009525 $929.4000 $71.4400
OCCT -97530TL OT SESSION BY LICENSED OT 2 2 7.761904 $554.5100 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 29 30 127.195239 $9086.8300 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 3 4 15.969047 $1140.8300 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 5 7 27.019048 $1930.2400 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 20 23 116.766667 $8341.8000 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 3 4.738888 $338.5400 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 6 6 42.600000 $3043.3500 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 26 31 164.019051 $11717.5300 $71.4400
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Subtotal (Total Children Is Unduplicated) 345 517 2110.188101 $121983.8300 $57.8100
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Total 555 2132.221435 $122607.2300 $57.5000
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Number of Children (Unduplicated) With at Least One Authorization 351