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: 01-01-23 and 03-31-23 Date of Report: 04-20-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 788 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 6 6 10.411111 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 6 6 10.411111 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 6 7 3.022222 $146.5800 $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 21 21 10.955554 $241.7900 $22.0700
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Subtotal (Total Children Is Unduplicated) 31 33 18.977776 $485.9100 $25.6000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 7 4.977778 $24889.0000 $5000.0200
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $231.6200 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 6 8 5.827778 $291.3900 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 2 2 1.250000 $62.5000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 2 2 0.291667 $14.5900 $50.0100
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 1.733333 $86.6700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 36 36 35.388095 $1769.4000 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 3 3 5.000000 $250.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.916667 $22.9200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 20 22 22.316667 $1115.8400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 21 22 24.849206 $1242.4600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 2.866667 $71.6700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 8 8 40.876192 $2043.8100 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 189 193 980.233338 $49011.6200 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 18 19 74.271432 $3713.5700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 267 347 1445.959531 $14459.5900 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 13 13 64.588097 $4647.7700 $71.9600
OCCT -97530TL OT SESSION BY LICENSED OT 12 13 52.342858 $3766.6000 $71.9600
OCCT -97530TLGT OT SESSION BY LICENSED OT 2 2 6.371429 $458.4900 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 10 10 57.690477 $4151.4100 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 6 6 25.850001 $1860.1700 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 2 2 7.857143 $565.4000 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 12 12 71.155553 $5120.3600 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 3 26.571428 $1912.0900 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 13 14 66.976190 $4819.6100 $71.9600
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Subtotal (Total Children Is Unduplicated) 293 749 3027.161527 $126578.5000 $41.8100
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Total 788 3056.550414 $127064.4100 $41.5700
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Number of Children (Unduplicated) With at Least One Authorization 299