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: 07-01-21 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 562 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 3 3 3.800001 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 3 3 3.800001 $0.0000 $0.0000
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 1 1 1.000000 $56.4900 $56.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.177778 $2.4700 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 34 34 32.826984 $778.0000 $23.7000
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.000000 $90.0000 $45.0000
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 2.000000 $102.1000 $51.0500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 44 46 45.004762 $1368.5600 $30.4100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 5 5.094444 $25472.0000 $4999.9600
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.388889 $27.8500 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $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 3 3 2.022222 $101.1100 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 3 3 9.792858 $489.6400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 5 5 3.477777 $173.8900 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 21 23 24.192063 $1209.5900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 4 4 5.900000 $147.5000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 1.000000 $50.0000 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 8 8 9.066666 $453.3300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 6 6 8.416666 $420.8300 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 11 11 9.711110 $485.5500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 37 40 221.776188 $11088.8100 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 207 217 1058.126978 $52906.3600 $50.0000
INTR -T1013 INTERPRETER 1 1 6.142857 $307.1500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 39 48 208.436507 $2084.3600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 7 7 29.147617 $2082.3000 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 11.419047 $815.7700 $71.4400
OCCT -97530TL OT SESSION BY LICENSED OT 7 9 37.400002 $2671.8700 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 30 33 96.202379 $6872.7100 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 2 2 5.285714 $377.6200 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 0.366667 $26.2000 $71.4500
PHY -97110TL PT SESSION BY LICENSED PT 2 3 8.666666 $619.1400 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 10 10 27.000000 $1928.8800 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 5 5 25.565080 $1826.3800 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 16.295238 $1164.1400 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 8 9 35.152380 $2511.2800 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 35 37 168.504761 $12037.9900 $71.4400
SPL -92508TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 6.000000 $83.2800 $13.8800
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 336 513 2053.050776 $129240.5200 $62.9500
-------------------------------------------------------------------------------------------------------------------------------------
Total 562 2101.855539 $130609.0800 $62.1400
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 340