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: 04-01-23 and 06-30-23 Date of Report: 07-25-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 940 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 12 11.266666 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 1.000000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 12 13 12.266666 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 2 2.000000 $97.0000 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 22 22 12.422225 $274.1600 $22.0700
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 1.000000 $75.0000 $75.0000
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Subtotal (Total Children Is Unduplicated) 25 25 15.422225 $446.1600 $28.9300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.000000 $15000.0000 $5000.0000
AUDE -V5160 DISPENSING FEE BINAURAL 4 4 3.455556 $800.3900 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 4 5 4.250000 $212.5000 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 7 9 8.500000 $425.0000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 4 5 4.694444 $234.7200 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 1 1 0.622222 $31.1100 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 50 52 42.022223 $2101.1200 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 1 1 2.000000 $100.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 2.227778 $55.7000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 16 16 8.272222 $413.6100 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 1 1 0.750000 $37.5000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 17 17 14.857144 $742.8600 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 1 1 1.500000 $75.0000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 2.000000 $50.0000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 4.714286 $235.7200 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 201 221 1068.634927 $53431.7200 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 22 24 104.504760 $5225.2300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 312 424 1698.965884 $20387.5900 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 20 24 95.904764 $6901.3100 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 2.285714 $164.4800 $71.9600
OCCT -97530TL OT SESSION BY LICENSED OT 17 17 66.276191 $4769.2300 $71.9600
OCCT -97530TLGT OT SESSION BY LICENSED OT 2 2 16.571428 $1192.4900 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 12 13 66.471431 $4783.2700 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 19 19 104.155558 $7495.0400 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 2 2 12.714286 $914.9200 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 19 21 96.961906 $6977.3900 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 13.301587 $957.1800 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 12 12 66.400000 $4778.1500 $71.9600
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Subtotal (Total Children Is Unduplicated) 334 902 3516.014311 $138493.2100 $39.3900
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Total 940 3543.703202 $138939.3700 $39.2100
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Number of Children (Unduplicated) With at Least One Authorization 346