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: 01-01-22 and 03-31-22 Date of Report: 04-16-22 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 605 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 10 10 8.122222 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 10 10 8.122222 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 5 5 4.022222 $195.0800 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $55.7100 $55.7100
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.327778 $4.7800 $14.5800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 34 34 24.257145 $570.0500 $23.5000
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.000000 $90.0000 $45.0000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 1.000000 $55.5000 $55.5000
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 0.400000 $21.0300 $52.5700
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Subtotal (Total Children Is Unduplicated) 44 45 33.007145 $992.1400 $30.0600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 2.144444 $10722.0000 $4999.9000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.066667 $4.5900 $68.8900
AUDE -V5160 DISPENSING FEE BINAURAL 4 4 4.000000 $920.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 7 8 6.250000 $312.5000 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 8 10 9.116667 $455.8400 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1 1 1.666667 $83.3400 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 6 6 5.351588 $267.5800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 7 7 8.222223 $411.1200 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 23 23 39.592065 $1979.6100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 1.377778 $34.4500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 8 9 26.225397 $1311.2800 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 7 7 8.333334 $416.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 6 6 4.150001 $207.5100 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 8 9 9.327777 $466.3900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 49 50 266.407939 $13320.4000 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 197 213 924.865880 $46243.2700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 64 73 300.782540 $3007.8200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 3 3 21.666667 $1547.8700 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 4.000000 $285.7600 $71.4400
OCCT -97530TL OT SESSION BY LICENSED OT 11 11 37.276192 $2663.0100 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 27 31 94.671431 $6763.3200 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 2 3 16.761905 $1197.4600 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 0.642857 $45.9300 $71.4400
PHY -97110TL PT SESSION BY LICENSED PT 9 9 30.361904 $2169.0500 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 13 13 64.000000 $4572.1500 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 3 23.495239 $1678.5000 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 20.490476 $1463.8300 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 11 11 69.438096 $4960.6600 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 27 28 155.288096 $11093.7900 $71.4400
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Subtotal (Total Children Is Unduplicated) 333 550 2155.973830 $118605.6700 $55.0100
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Total 605 2197.103197 $119597.8100 $54.4300
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Number of Children (Unduplicated) With at Least One Authorization 345