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: 07-01-22 and 09-30-22 Date of Report: 10-19-22 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 707 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 9 9 8.566667 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 9 9 8.566667 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 2 1.038889 $50.3900 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 5 5 5.000000 $97.5500 $19.5100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 19 19 9.649999 $212.9700 $22.0700
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Subtotal (Total Children Is Unduplicated) 25 26 15.688888 $360.9100 $23.0000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 2.038889 $10194.5000 $5000.0300
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 3 1.622222 $81.1100 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 4 4 6.469047 $323.4500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 34 34 32.568256 $1628.4200 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 2 2 1.733333 $86.6700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 18 18 18.227778 $911.3900 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 1 1 1.000000 $50.0000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 15 15 16.499998 $824.9900 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 2 2 2.000000 $100.0000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 2.200000 $55.0000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 7 8 45.842856 $2292.1500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 167 171 875.742859 $43787.1400 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 31 32 185.133333 $9256.6700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 252 305 1336.623017 $13366.2400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 12 12 54.014285 $3886.8800 $71.9600
OCCT -97530TL OT SESSION BY LICENSED OT 10 10 51.171430 $3682.2900 $71.9600
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 11.428571 $822.4000 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 11 12 38.523809 $2772.1700 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 4 5 21.800000 $1568.7300 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 2 2 24.857142 $1788.7200 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 15 17 92.580952 $6662.1400 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 2 6.285714 $452.3300 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 9 9 24.680953 $1776.0400 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 3 3 25.409524 $1828.4700 $71.9600
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Subtotal (Total Children Is Unduplicated) 287 672 2878.453968 $108197.9000 $37.5900
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Total 707 2902.709523 $108558.8100 $37.4000
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Number of Children (Unduplicated) With at Least One Authorization 296