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: 10-01-23 and 12-31-23 Date of Report: 01-14-24 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 857 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 17 17 30.861111 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 17 17 30.861111 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 7 7 6.194444 $300.4300 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 33 33 16.761110 $369.9200 $22.0700
SPCH -92521TL EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.4100 $51.4100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 2 2 13.714285 $705.0500 $51.4100
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 42 43 37.669839 $1426.8100 $37.8800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 7 9 7.438888 $37194.0000 $4999.9400
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $231.6200 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 7 8 9.628571 $481.4300 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 1 1 1.000000 $50.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 7 8 15.495238 $774.7700 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 1 1 1.000000 $50.0000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 38 40 79.943652 $3997.1900 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 3 3 2.461111 $123.0600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.166667 $4.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 18 18 26.722221 $1336.1100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 28 29 31.689680 $1584.4800 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 1 1 2.133333 $106.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.966667 $49.1700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 207 213 888.068254 $44403.4000 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 14 16 40.942859 $2047.1500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 242 294 1197.873020 $14374.4600 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 30 31 202.090477 $14542.4300 $71.9600
OCCT -97530TL OT SESSION BY LICENSED OT 23 23 95.133334 $6845.8100 $71.9600
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 1.533333 $110.3400 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 10 10 58.657144 $4220.9600 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 3 3 25.280953 $1819.2200 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 21 21 108.796826 $7829.0300 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 2 2 11.000000 $791.5600 $71.9600
SENS -V5060 BEHIND EAR HEARING AID 1 1 1.000000 $229.6100 $229.6100
SENS -V5264 EARMOLD 1 1 1.000000 $18.1300 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 22 25 91.790476 $6605.2400 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 2 1.500000 $107.9400 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 29 32 115.215875 $8290.9400 $71.9600
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 365 797 3021.528579 $158243.8600 $52.3700
-------------------------------------------------------------------------------------------------------------------------------------
Total 857 3090.059529 $159670.6600 $51.6700
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 384