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: 07-01-20 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 2349 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 28 33 63.094444 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 3 3 16.400000 $606.8000 $37.0000
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Subtotal (Total Children Is Unduplicated) 31 36 79.494444 $606.8000 $7.6300
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 10 10 8.988888 $435.9600 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 9 10 8.833333 $498.9900 $56.4900
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.000000 $23.4900 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 12 12 9.311111 $129.1500 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 62 70 55.922225 $1325.3600 $23.7000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.455556 $20.5000 $45.0000
EXIT -EXIT EXIT ASSESSMENT 1 1 2.000000 $100.0000 $50.0000
SCREEN-T1023 SCREENING 2 2 5.688889 $284.4500 $50.0000
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Subtotal (Total Children Is Unduplicated) 97 107 92.200002 $2817.9000 $30.5600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 9 12 14.322222 $71611.0000 $4999.9900
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.855556 $92.7800 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 1.561111 $111.7900 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 12 13 12.955556 $2979.7900 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 18 23 20.261112 $1013.0600 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 34 36 27.999999 $1400.0100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 4 4 13.295237 $664.7600 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 10 12 47.038890 $2351.9500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 4 4 20.361904 $509.0500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 61 66 144.784126 $7239.2000 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 73 87 264.717459 $13235.8700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 10 10 38.850000 $971.2500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 20 21 57.944446 $2897.2300 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 30 36 127.816666 $6390.8300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 16.400000 $410.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 48 55 144.665081 $7233.2600 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 49 54 115.471426 $5773.5600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 11 11 18.788888 $469.7200 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 1.000000 $73.3200 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 21.714285 $542.8600 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 5 7 27.945237 $1397.2600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 347 393 3751.957525 $187597.8700 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 439 586 7240.916651 $362045.8900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 292 360 2094.192051 $20941.9300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 43 50 429.917460 $30713.3200 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 12 13 171.723809 $12267.9300 $71.4400
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 4.142857 $236.9700 $57.2000
OCCT -97530TL OT SESSION BY LICENSED OT 5 5 40.047617 $2861.0100 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 66 94 965.611109 $68983.3000 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 34 38 418.591268 $29904.1600 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 12 19 203.220635 $14518.0900 $71.4400
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 1 1 5.466667 $312.4800 $57.1600
PHY -97110TLGT PT SESSION BY LICENSED PT 40 53 671.814283 $47994.4100 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 26 34 333.119842 $23798.1100 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 23 26 374.480952 $26752.9400 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 55 69 808.179369 $57736.3400 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 14.733334 $204.5000 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 1 1 7.142857 $264.2900 $37.0000
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Subtotal (Total Children Is Unduplicated) 906 2206 18676.007487 $1014527.0800 $54.3200
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Total 2349 18847.701933 $1017951.7700 $54.0100
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Number of Children (Unduplicated) With at Least One Authorization 916