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: 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 915 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 15 16 13.399998 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 16 17 13.649998 $9.2500 $0.6800
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 3 3 0.822222 $39.8800 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 8 8 8.000000 $188.0000 $23.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 60 60 38.349208 $901.2100 $23.5000
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Subtotal (Total Children Is Unduplicated) 71 71 47.171430 $1129.0900 $23.9400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 0.511111 $2555.5000 $4999.8900
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 5 5 4.283333 $214.1700 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 2 2 2.000000 $100.0000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1 1 1.622222 $81.1100 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 26 29 24.183332 $1209.1600 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 5 5 3.005555 $150.2800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.366667 $9.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 20 21 27.892065 $1394.6100 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 3 3 14.021429 $701.0700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 19 19 14.811110 $740.5500 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 3 3 3.000000 $150.0000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.344444 $8.6100 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 10 11 621.199999 $31060.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 213 224 1130.049186 $56502.4800 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 40 42 264.147617 $13207.3800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 290 357 1516.940444 $15169.4100 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 11 11 49.242856 $3517.9100 $71.4400
OCCT -97530TL OT SESSION BY LICENSED OT 16 17 84.409522 $6030.2200 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 10.857143 $775.6300 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 8 8 42.015872 $3001.6100 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 0.088889 $6.3500 $71.4500
PHY -97110TL PT SESSION BY LICENSED PT 18 18 93.647617 $6690.1900 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 1 1 4.357143 $311.2700 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 16 17 95.409521 $6816.0700 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 20 20 110.833332 $7917.9500 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 6 6 23.809525 $1700.9500 $71.4400
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Subtotal (Total Children Is Unduplicated) 365 827 4144.049934 $160251.6400 $38.6700
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Total 915 4204.871362 $161389.9800 $38.3800
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Number of Children (Unduplicated) With at Least One Authorization 382