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: 10-01-21 and 12-31-21 Date of Report: 02-04-22 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 627 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 5 5 11.671429 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 5 5 11.671429 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 2 2.000000 $97.0000 $48.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.500000 $11.7500 $23.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 5 5 1.149999 $16.7700 $14.5800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 24 24 13.183332 $309.8100 $23.5000
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Subtotal (Total Children Is Unduplicated) 32 32 16.833331 $435.3200 $25.8600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.000000 $10000.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.000000 $50.0000 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 5 5 3.422222 $787.1100 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 5 5.000000 $250.0000 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 6 6 7.542857 $377.1500 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 2 2 1.194444 $59.7200 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 5 6 13.142857 $657.1500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 12 12 18.388889 $919.4500 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 21 21 26.360318 $1318.0100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.633333 $15.8300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 4 4 3.711906 $185.6000 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 18 20 27.896826 $1394.8400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 9 9 9.133334 $456.6700 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 15 15 11.057144 $552.8600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 2.000000 $50.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 64 68 326.654767 $16332.7400 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 211 220 1074.355567 $53717.7600 $50.0000
INTR -T1013 INTERPRETER 1 1 2.857143 $142.8600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 60 64 235.430955 $2354.3100 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 7 7 19.080953 $1363.1500 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 5 5 20.823810 $1487.6500 $71.4400
OCCT -97530TL OT SESSION BY LICENSED OT 8 8 17.790477 $1270.9500 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 26 27 207.880953 $14851.0200 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 3 3 10.652381 $761.0100 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 4 4 7.161905 $511.6500 $71.4400
PHY -97110TL PT SESSION BY LICENSED PT 6 6 13.166666 $940.6200 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 10 10 36.490475 $2606.8800 $71.4400
SENS -V5264 EARMOLD 1 1 1.133333 $20.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 8 8 47.000000 $3357.6800 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 4 4 29.142858 $2081.9700 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 8 8 44.673016 $3191.4400 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 33 35 192.614289 $13760.3500 $71.4400
SPL -92508TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 4.933333 $68.4700 $13.8800
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Subtotal (Total Children Is Unduplicated) 369 590 2424.327011 $135895.2800 $56.0500
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Total 627 2452.831771 $136330.6000 $55.5800
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Number of Children (Unduplicated) With at Least One Authorization 373