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: 07-01-21 and 09-30-21 Date of Report: 10-13-21 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 641 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 4 4 4.788890 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 1.833333 $67.8300 $37.0000
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Subtotal (Total Children Is Unduplicated) 5 5 6.622223 $67.8300 $10.2400
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 2 2 2.000000 $112.9800 $56.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 4 4 0.922222 $12.7900 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 15 15 8.905555 $211.0600 $23.7000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.250000 $21.2100 $84.8400
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 2.000000 $102.1000 $51.0500
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Subtotal (Total Children Is Unduplicated) 25 25 16.077777 $557.1400 $34.6500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 6.571429 $32857.0000 $4999.9800
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 1.511111 $347.5500 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 6 9 8.250000 $412.5000 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 4 5 3.250000 $162.5000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 5 5 5.383333 $269.1700 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 6 6 5.877778 $293.8900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 14 15 18.222221 $911.1100 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 30 30 34.404762 $1720.2400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 6 6 6.766667 $169.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 5 5 8.199999 $410.0000 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 12 12 21.157142 $1057.8500 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.000000 $25.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 9 9 8.116666 $405.8300 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 17 17 19.883333 $994.1700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 1.500000 $37.5000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 58 61 275.473017 $13773.6500 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 174 191 886.909524 $44345.4600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 58 71 231.899206 $2318.9900 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 11 11 36.341270 $2596.2200 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 4 4 19.790477 $1413.8300 $71.4400
OCCT -97530TL OT SESSION BY LICENSED OT 7 7 18.014287 $1286.9500 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 32 33 122.880952 $8778.6100 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 4 5 25.428572 $1816.6100 $71.4400
PHY -97110TL PT SESSION BY LICENSED PT 4 4 23.466667 $1676.4600 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 28 28 94.423811 $6745.6500 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 7 10 30.522222 $2180.5100 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 6 7 35.823810 $2559.2600 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 10 13 50.633332 $3617.2300 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 34 37 194.714287 $13910.3700 $71.4400
SPL -92508TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 0.733333 $10.1800 $13.8800
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Subtotal (Total Children Is Unduplicated) 345 611 2197.149208 $147103.4200 $66.9500
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Total 641 2219.849208 $147728.3900 $66.5500
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Number of Children (Unduplicated) With at Least One Authorization 349