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: 07-01-21 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 2643 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 35 38 67.765873 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 1.833333 $67.8300 $37.0000
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Subtotal (Total Children Is Unduplicated) 37 40 69.849206 $77.0800 $1.1000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 13 15 14.516667 $704.0600 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 2 3 3.000000 $167.1300 $55.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.011111 $23.7600 $23.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 10 10 5.183333 $75.5700 $14.5800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 101 104 141.636506 $3328.4600 $23.5000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.250000 $21.2100 $84.8400
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
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 2.000000 $102.1000 $51.0500
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 0.400000 $21.0300 $52.5700
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Subtotal (Total Children Is Unduplicated) 130 139 170.997617 $4588.8200 $26.8400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 10 13 15.815874 $79079.5000 $5000.0100
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.000000 $50.0000 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.966667 $66.5700 $68.8600
AUDE -V5160 DISPENSING FEE BINAURAL 18 18 20.455555 $4704.7700 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 18 25 22.500000 $1125.0000 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 25 30 61.869047 $3093.4600 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 10 10 19.711111 $985.5600 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 17 20 78.883334 $3944.1800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.000000 $25.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 46 51 127.588889 $6379.4500 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 74 87 222.681744 $11134.0800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 15 15 18.538890 $463.4800 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 24 29 108.566668 $5428.3400 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 44 54 192.462699 $9623.1300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.000000 $25.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 33 34 69.883333 $3494.1700 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 48 52 117.176983 $5858.8500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 6 6 7.494445 $187.3600 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 14.857143 $742.8600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 214 267 2825.237302 $141261.8600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 569 847 9796.034908 $489801.7400 $50.0000
INTR -T1013 INTERPRETER 2 2 11.433333 $571.6700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 237 352 2893.468246 $28934.6800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 25 29 303.531746 $21684.3000 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 11 13 103.742856 $7411.3800 $71.4400
OCCT -97530TL OT SESSION BY LICENSED OT 29 39 304.114284 $21725.9300 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 87 115 1108.056349 $79159.5600 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 12 16 115.642857 $8261.5100 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 4 5 35.985713 $2570.8100 $71.4400
PHY -97110TL PT SESSION BY LICENSED PT 27 34 278.995235 $19931.4200 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 58 66 496.180951 $35447.1700 $71.4400
SENS -V5264 EARMOLD 1 1 3.177778 $57.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 25 30 329.379363 $23530.8600 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 13 15 163.552381 $11684.1900 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 30 45 533.152381 $38088.4100 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 106 135 1714.261905 $122466.8600 $71.4400
SPL -92508TLGT SPL THERAPY SESSION BY LICENSED SLP 2 3 23.866666 $331.2700 $13.8800
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Subtotal (Total Children Is Unduplicated) 940 2464 22142.266636 $1189331.5300 $53.7100
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Total 2643 22383.113459 $1193997.4300 $53.3400
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Number of Children (Unduplicated) With at Least One Authorization 962