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: 07-01-23 and 09-30-23 Date of Report: 10-10-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 579 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 12 12 15.705557 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 12 12 15.705557 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 5 5 4.344444 $210.7000 $48.5000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 1.000000 $15.8400 $15.8400
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 22 22 11.772223 $259.8100 $22.0700
EXIT -EXIT COS Exit 1 1 1.000000 $50.0000 $50.0000
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 2 2 26.142857 $1344.0000 $51.4100
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Subtotal (Total Children Is Unduplicated) 30 31 44.259524 $1880.3600 $42.4800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 5 4.344444 $21722.0000 $4999.9500
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 2.000000 $463.2400 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 7 8 4.919047 $245.9500 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 4 4 3.250000 $162.5000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 4 4 4.144445 $207.2300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 32 35 49.525082 $2476.2600 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 3 3 2.377778 $118.8900 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 18 19 27.000002 $1350.0100 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 1 1 0.933333 $46.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 23 23 36.558728 $1827.9300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.200000 $5.0000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 9.495238 $474.7700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 162 171 802.485723 $40124.2600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 9 9 53.752381 $2687.6100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 114 132 652.096033 $7825.1500 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 24 26 115.904762 $8340.5000 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 2 8.285714 $596.2400 $71.9600
OCCT -97530TL OT SESSION BY LICENSED OT 15 16 88.952382 $6401.0100 $71.9600
OCCT -97530TLGT OT SESSION BY LICENSED OT 2 2 6.600000 $474.9400 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 13 13 78.619048 $5657.4200 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 8 8 62.895237 $4525.9400 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 1 1 1.733333 $124.7300 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 23 24 128.057143 $9214.9700 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 0.566667 $40.7800 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 22 23 113.731747 $8184.1300 $71.9600
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Subtotal (Total Children Is Unduplicated) 305 536 2259.428267 $123323.1100 $54.5800
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Total 579 2319.393348 $125203.4700 $53.9800
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Number of Children (Unduplicated) With at Least One Authorization 316