Summary Report for FSPSAs Initiated During the Report Period Center: 04
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: 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 1465 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 33 33 20.841269 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 33 33 20.841269 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.238889 $12.2000 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.327778 $16.7300 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 38 42 14.303174 $730.1700 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 0.227778 $11.6300 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 34 37 9.538889 $486.9600 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 6 6 1.827778 $93.3100 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 21 21 19.677777 $876.6400 $44.5500
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Subtotal (Total Children Is Unduplicated) 79 110 46.142063 $2227.6400 $48.2800
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 26 62 32.457142 $1622.8600 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1 1 0.005556 $0.2800 $50.4000
CONOP -CONOP CONSULT, OT, PHONE 2 2 0.527778 $13.2000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 0.005556 $0.2800 $50.4000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.422222 $10.5600 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 58 68 516.142855 $12903.5800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 492 511 3634.811892 $181740.8000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 487 509 3589.954748 $35899.5900 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 28 30 185.928568 $13282.7800 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 35 35 237.495240 $13584.7300 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 24 28 141.349207 $10098.0100 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 5.642857 $403.1300 $71.4400
PHY -97110HM PT SESSION BY PT ASST 27 27 176.357144 $10080.5700 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 1 1 12.714286 $726.7500 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 16 16 104.142855 $7439.9800 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 4.785714 $273.7400 $57.2000
SPL -92508HA GROUP SPL SESSION PER CHILD 28 28 191.785715 $2661.9800 $13.8800
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Subtotal (Total Children Is Unduplicated) 569 1322 8834.529335 $290742.8000 $32.9100
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Total 1465 8901.512667 $292970.4400 $32.9100
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Number of Children (Unduplicated) With at Least One Authorization 597