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 858 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
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Subtotal (Total Children Is Unduplicated) 28 33 63.094444 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 9 9 7.988888 $387.4600 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.000000 $23.7000 $23.7000
EXIT -EXIT EXIT ASSESSMENT 1 1 2.000000 $100.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 11 11 10.988888 $511.1600 $46.5200
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.855556 $92.7800 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $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
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 5 7 27.945237 $1397.2600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 6 6 18.685714 $934.2900 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 12 14 150.457143 $7522.8600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 292 360 2094.192051 $20941.9300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 4.000000 $285.7600 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 20.857143 $1490.0300 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 2.000000 $142.8800 $71.4400
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 1 1 7.142857 $264.2900 $37.0000
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Subtotal (Total Children Is Unduplicated) 474 814 3387.530935 $83886.8000 $24.7600
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Total 858 3461.614267 $84397.9500 $24.3800
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Number of Children (Unduplicated) With at Least One Authorization 492