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: 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 2927 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 39 44 69.304761 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 40 45 69.554761 $9.2500 $0.1300
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 14 19 15.666667 $759.8400 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $55.7100 $55.7100
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 8 8 8.000000 $188.0000 $23.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.016667 $14.8200 $14.5800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 160 170 185.152382 $4351.0900 $23.5000
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 2.822222 $127.0000 $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) 186 205 217.057938 $5675.0800 $26.1500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 10 14 12.755556 $63778.0000 $5000.0200
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.966667 $66.5700 $68.8600
AUDE -V5160 DISPENSING FEE BINAURAL 14 15 19.033334 $4377.6800 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 20 27 23.783333 $1189.1700 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 24 29 58.935714 $2946.7900 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 6 6 13.644444 $682.2200 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 10 11 44.484127 $2224.2100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.000000 $25.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 48 58 106.827778 $5341.3900 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 62 71 206.620633 $10331.0200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 15 16 38.407937 $960.2000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 37 51 150.230956 $7511.5700 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 31 40 146.193652 $7309.6800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 35 39 67.422221 $3371.1100 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 30 32 91.570635 $4578.5400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 5 8.405556 $210.1400 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 16 18 719.628569 $35981.4300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 372 426 3791.853945 $189592.7400 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 502 676 8768.066639 $438403.3800 $50.0000
INTR -T1013 INTERPRETER 1 1 9.000000 $450.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 439 648 4528.248370 $45282.5000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 23 29 320.142855 $22871.0000 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 7 7 51.857142 $3704.6600 $71.4400
OCCT -97530TL OT SESSION BY LICENSED OT 37 48 396.466662 $28323.6000 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 57 77 856.437301 $61183.9200 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 18 23 223.515870 $15967.9700 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 3 4 18.312698 $1308.2500 $71.4400
PHY -97110TL PT SESSION BY LICENSED PT 37 51 404.647614 $28908.0400 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 39 45 440.528571 $31471.3600 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 31 37 374.085711 $26724.7000 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 8 9 92.766666 $6627.2600 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 45 54 546.614284 $39050.1500 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 85 106 1502.895236 $107366.8500 $71.4400
SPL -92508TLGT SPL THERAPY SESSION BY LICENSED SLP 1 2 23.133333 $321.0900 $13.8800
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Subtotal (Total Children Is Unduplicated) 987 2677 24058.484009 $1198442.1700 $49.8100
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Total 2927 24345.096708 $1204126.5100 $49.4600
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Number of Children (Unduplicated) With at Least One Authorization 1012