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: 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 2249 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 24 30 72.988889 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 3 4 18.533333 $685.7300 $37.0000
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Subtotal (Total Children Is Unduplicated) 27 34 91.522222 $685.7300 $7.4900
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 6 7 7.000000 $339.5000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 10 11 9.833333 $555.4800 $56.4900
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 1.011111 $23.7500 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 19 19 11.261111 $156.1900 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 73 77 63.116671 $1495.8800 $23.7000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.744444 $63.1500 $84.8300
EXIT -EXIT EXIT ASSESSMENT 1 1 2.000000 $100.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 110 118 94.966670 $2733.9600 $28.7900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 9 11 34.006349 $170032.0000 $5000.0100
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.000000 $50.0000 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 3 3 2.527778 $181.0200 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 16 18 16.016667 $3683.8400 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 17 22 19.261112 $963.0600 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 34 36 27.999999 $1400.0100 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 5 5 7.255556 $362.7800 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 20 22 87.475397 $4373.7800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 3 3 3.933333 $98.3300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 42 48 131.160318 $6558.0200 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 86 110 279.138884 $13956.9200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 10 11 41.683333 $1042.0800 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 12 13 28.727778 $1436.3900 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 35 45 174.821426 $8741.0700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 2 17.400000 $435.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 38 45 97.911112 $4895.5600 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 56 64 139.408727 $6970.4200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 12 13 20.644444 $516.1100 $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 3 3 8.333333 $416.6700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 221 260 3148.442439 $157422.1300 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 538 741 8459.172184 $422958.6300 $50.0000
INTR -T1013 INTERPRETER 1 1 3.733333 $186.6700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 115 158 1106.090476 $11060.9000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 30 36 252.849204 $18063.5300 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 12 16 178.133333 $12725.8400 $71.4400
OCCT -97530TL OT SESSION BY LICENSED OT 6 7 63.142855 $4510.9200 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 86 122 1145.137295 $81808.6400 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 11 16 245.350794 $17527.8400 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 6 13 116.958730 $8355.5300 $71.4400
PHY -97110TL PT SESSION BY LICENSED PT 7 7 6.300000 $450.0700 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 51 72 757.828568 $54139.2800 $71.4400
SENS -V5264 EARMOLD 1 1 0.933333 $16.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 24 30 227.727779 $16268.8900 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 18 22 318.461905 $22750.9400 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 13 13 63.888892 $4564.2400 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 77 99 1002.322223 $71605.9300 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 11.866667 $164.7100 $13.8800
SPL -92508TLGT SPL THERAPY SESSION BY LICENSED SLP 2 2 9.733334 $135.1000 $13.8800
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Subtotal (Total Children Is Unduplicated) 952 2097 18279.493175 $1131445.8000 $61.9000
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Total 2249 18465.982067 $1134865.4900 $61.4600
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Number of Children (Unduplicated) With at Least One Authorization 963