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: 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 653 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 11 11 7.238888 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 11 11 7.238888 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 7 8 6.316666 $306.3600 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 46 46 20.661113 $485.5400 $23.5000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.316667 $14.2500 $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) 56 57 28.694446 $882.6700 $30.7600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 5 5.000000 $25000.0000 $5000.0000
AUDE -V5160 DISPENSING FEE BINAURAL 5 5 2.033333 $467.6600 $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 -CONIFGT CONSULT,ITDS,FACE TO FACE 2 2 1.033333 $51.6700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.000000 $25.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 12 12 8.849999 $442.5000 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 21 22 18.022223 $901.1200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 6 6 5.138890 $128.4800 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 12 12 18.927777 $946.3900 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 9 9 13.516667 $675.8400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 6 6 4.750000 $237.5000 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 13 13 16.377778 $818.8900 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 6.714285 $335.7200 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 68 69 293.033332 $14651.6900 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 166 173 873.687288 $43684.4200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 90 103 311.998408 $3119.9900 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 4 4 20.000000 $1428.8000 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 0.666667 $47.6300 $71.4400
OCCT -97530TL OT SESSION BY LICENSED OT 10 10 27.895237 $1992.8500 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 16 19 74.211903 $5301.7100 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 9 10 57.942857 $4139.4500 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 2 2 0.742857 $53.0700 $71.4400
PHY -97110TL PT SESSION BY LICENSED PT 14 14 48.742857 $3482.2000 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 16 16 68.952381 $4925.9600 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 10 10 42.652380 $3047.0900 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 6.595237 $471.1600 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 10 10 17.471428 $1248.1600 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 28 28 148.271428 $10592.5200 $71.4400
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Subtotal (Total Children Is Unduplicated) 334 585 2109.595212 $128985.7500 $61.1400
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Total 653 2145.528546 $129868.4300 $60.5300
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Number of Children (Unduplicated) With at Least One Authorization 345