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: 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 614 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 8 9 16.049207 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 8 9 16.049207 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 2 1.494444 $72.4800 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 27 27 15.944443 $374.6900 $23.5000
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Subtotal (Total Children Is Unduplicated) 29 29 17.438887 $447.1700 $25.6400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.494444 $2472.0000 $4999.5600
AUDE -V5160 DISPENSING FEE BINAURAL 9 9 7.350000 $1690.5000 $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 14.447619 $722.3800 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1 1 0.094444 $4.7200 $49.9800
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 4 4 20.872221 $1043.6100 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 9 10 12.388889 $619.4500 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 15 16 31.271431 $1563.5800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 4 4 3.722222 $93.0600 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 13 15 32.069047 $1603.4500 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 16 17 28.100001 $1405.0000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 7 7 5.783333 $289.1700 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 4 4 15.658730 $782.9400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 0.944444 $23.6100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 65 71 380.558729 $19027.9600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 189 200 1078.437296 $53921.8700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 76 91 308.292857 $3082.9300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 5 5 29.704762 $2122.1000 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 6.200000 $442.9300 $71.4400
OCCT -97530TL OT SESSION BY LICENSED OT 10 10 36.695237 $2621.5100 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 21 21 230.065081 $16435.8600 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 5 5 30.190476 $2156.8200 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 4.066667 $290.5300 $71.4400
PHY -97110TL PT SESSION BY LICENSED PT 9 9 23.947618 $1710.8100 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 16 17 78.123808 $5581.1600 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 4 4 8.523809 $608.9500 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 4.009524 $286.4500 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 11 11 64.838094 $4632.0300 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 24 25 137.342856 $9811.7700 $71.4400
SPL -92508TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 1.200000 $16.6600 $13.8800
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Subtotal (Total Children Is Unduplicated) 341 576 2600.393639 $135313.7600 $52.0400
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Total 614 2633.881733 $135760.9300 $51.5400
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Number of Children (Unduplicated) With at Least One Authorization 347