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: 04-01-22 and 06-30-22 Date of Report: 08-08-22 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 701 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
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 0.250000 $9.2500 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 16 16 16.255555 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 17 17 16.505555 $9.2500 $0.5600
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 6 6 6.000000 $291.0000 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 30 30 13.950001 $327.8300 $23.5000
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Subtotal (Total Children Is Unduplicated) 36 36 19.950001 $618.8300 $31.0200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 4.000000 $20000.0000 $5000.0000
AUDE -V5160 DISPENSING FEE BINAURAL 6 6 6.416667 $1475.8400 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 3 3.000000 $150.0000 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 3 3 3.300000 $165.0000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 2 2 0.916666 $45.8300 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 0.083333 $4.1700 $49.9800
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.000000 $25.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 16 17 23.583334 $1179.1700 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 12 12 8.244444 $412.2200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 5 5 1.772221 $44.3000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 10 10 13.433334 $671.6700 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 16 16 19.257143 $962.8600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 11 11 8.177777 $408.8900 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 10 10 6.321428 $316.0700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 1.550000 $38.7500 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 11.142858 $557.1400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 85 86 311.142862 $15557.1500 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 183 189 768.162711 $38408.1500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 125 141 554.059530 $5540.6000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 8 9 45.285715 $3235.2100 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 3 3 2.366667 $169.0800 $71.4400
OCCT -97530TL OT SESSION BY LICENSED OT 13 13 52.714287 $3765.9200 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 16 18 62.714287 $4480.3000 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 5 5 18.895238 $1349.8800 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 0.466667 $33.3400 $71.4400
PHY -97110TL PT SESSION BY LICENSED PT 13 13 48.104763 $3436.6100 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 13 13 40.890477 $2921.2200 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 9 9 62.604763 $4472.4800 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 2.800000 $200.0300 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 13 13 88.123811 $6295.5600 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 27 27 152.309528 $10881.0000 $71.4400
SPL -92508TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 5.000000 $69.4000 $13.8800
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Subtotal (Total Children Is Unduplicated) 353 648 2327.840511 $127272.8200 $54.6700
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Total 701 2364.296067 $127900.8900 $54.1000
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Number of Children (Unduplicated) With at Least One Authorization 368