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: 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 855 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 11 11 15.200001 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 1.600000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 12 12 16.800001 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 5 5 5.000000 $242.5000 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 30 30 11.944442 $263.6100 $22.0700
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 1 3.571429 $189.0300 $52.9300
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Subtotal (Total Children Is Unduplicated) 36 36 20.515871 $695.1400 $33.8800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 3.577778 $17889.0000 $5000.0300
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 1.861112 $431.0900 $231.6300
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 6 9 14.642858 $732.1400 $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 4 5 4.738888 $236.9400 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 0.133333 $6.6700 $49.9900
CONOF -CONOF CONSULT, OT, FACE TO FACE 45 46 40.114288 $2005.7300 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 3 3 5.600000 $280.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.066667 $26.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 17 18 26.805555 $1340.2800 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 1 1 2.000000 $100.0000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 21 23 33.734129 $1686.7100 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 14 15 49.052379 $2452.6200 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 186 196 977.652377 $48882.6200 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 10 10 50.761906 $2538.0900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 302 380 1593.877779 $15938.7900 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 12 12 55.495238 $3993.4500 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 4.571429 $328.9600 $71.9600
OCCT -97530TL OT SESSION BY LICENSED OT 11 13 77.790476 $5597.8000 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 16 16 78.100000 $5620.0800 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 13 13 73.885714 $5316.8200 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 3 3 41.000000 $2950.3700 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 18 19 99.076190 $7129.5300 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 12 12 47.928573 $3448.9400 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 1.611111 $115.9300 $71.9600
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Subtotal (Total Children Is Unduplicated) 320 807 3286.327780 $129111.7100 $39.2900
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Total 855 3323.643652 $129806.8500 $39.0600
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Number of Children (Unduplicated) With at Least One Authorization 332