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: 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 626 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 1 1 1.033333 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 2.133333 $78.9300 $37.0000
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Subtotal (Total Children Is Unduplicated) 2 2 3.166666 $78.9300 $24.9300
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 2 2.000000 $97.0000 $48.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.011111 $0.2600 $23.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 7 7 1.961111 $27.2000 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 16 16 7.777779 $184.3400 $23.7000
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Subtotal (Total Children Is Unduplicated) 26 26 11.750001 $308.8000 $26.2800
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.000000 $50.0000 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 1.966667 $140.8400 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 5 5 3.477778 $799.8900 $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 -CONIF CONSULT, ITDS FACE TO FACE 3 3 3.638889 $181.9500 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 5 5 15.726984 $786.3600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.000000 $25.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 18 18 20.477777 $1023.8900 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 25 25 30.355554 $1517.7700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.000000 $25.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 4 4 5.433333 $271.6700 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 12 12 30.000792 $1500.0400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 10 12 14.227778 $711.3900 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 19 20 32.198413 $1609.9300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 4.500000 $112.5000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 53 53 282.880944 $14144.0600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 163 175 838.328556 $41916.4100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 68 84 220.356348 $2203.5600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 11 12 24.544444 $1753.4500 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 4 4 22.028571 $1573.7200 $71.4400
OCCT -97530TL OT SESSION BY LICENSED OT 5 5 12.428570 $887.8900 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 26 28 103.635712 $7403.7400 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 5 7 36.961905 $2640.5400 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 3 4 21.185714 $1513.5100 $71.4400
PHY -97110TL PT SESSION BY LICENSED PT 7 7 6.300000 $450.0700 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 17 20 84.804760 $6058.4600 $71.4400
SENS -V5264 EARMOLD 1 1 0.933333 $16.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 11 12 22.831746 $1631.1000 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 25.133333 $1795.5200 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 9 9 41.822224 $2987.7800 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 42 47 268.904761 $19210.5800 $71.4400
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Subtotal (Total Children Is Unduplicated) 341 598 2191.590442 $115618.6800 $52.7600
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Total 626 2206.507109 $116006.4100 $52.5700
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Number of Children (Unduplicated) With at Least One Authorization 342