Summary Report for FSPSAs Ending During the Report Period Center: 04
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: 10-01-21 and 12-31-21 Date of Report: 02-04-22 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1623 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 40 40 20.738892 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 40 40 20.738892 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 0.422222 $20.4800 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 3 3 2.571429 $143.2500 $55.7100
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.272222 $13.9000 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 3 3 0.816667 $41.6900 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 41 45 8.844447 $451.5200 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 0.794445 $40.5600 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 34 40 8.116669 $414.3700 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.072222 $3.6900 $51.0300
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 17 19 3.572222 $182.3600 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 8 9 2.033334 $90.5900 $44.5500
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Subtotal (Total Children Is Unduplicated) 85 124 27.515879 $1402.4000 $50.9700
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 15 41 8.033337 $401.6900 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1 1 0.005556 $0.2800 $50.4000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 0.477778 $11.9500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 2 2 0.261111 $13.0600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 3 5.740477 $143.5100 $25.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.644444 $16.1100 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 0.005556 $0.2800 $50.4000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 10.358730 $258.9700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 71 78 356.785722 $8919.6400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 539 580 3748.428584 $187421.4600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 2 2 6.714285 $335.7200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 531 578 3728.026200 $37280.2700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 45 50 249.978570 $17858.4900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 17 19 105.285717 $6022.3400 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 40 46 270.447619 $19320.7800 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 0.928571 $66.3400 $71.4400
PHY -97110HM PT SESSION BY PT ASST 7 9 47.000001 $2686.5200 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 1 1 0.428571 $24.5000 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 30 35 153.273814 $10949.8900 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 1.785714 $102.1400 $57.2000
SPL -92508HA GROUP SPL SESSION PER CHILD 6 7 32.500001 $451.1000 $13.8800
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Subtotal (Total Children Is Unduplicated) 636 1459 8727.110358 $292285.0100 $33.4900
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Total 1623 8775.365129 $293687.4100 $33.4700
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Number of Children (Unduplicated) With at Least One Authorization 672