Summary Report for FSPSAs Ending During the Report Period Center: 51
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 237 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 7 7 16.658731 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 1.344444 $49.7400 $37.0000
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Subtotal (Total Children Is Unduplicated) 9 9 18.003175 $49.7400 $2.7600
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 2 3 3.000000 $150.0000 $50.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 4 4 4.000000 $204.2000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 10 10 10.000000 $510.5000 $51.0500
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 7 7 6.285714 $320.8900 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.0500 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.0500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 3.000000 $133.6500 $44.5500
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Subtotal (Total Children Is Unduplicated) 30 32 31.285714 $1574.4900 $50.3300
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 0.750000 $37.5000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 0.066667 $1.6700 $25.0100
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 0.633333 $31.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 5.857143 $146.4300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 69 71 432.000002 $21600.0100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 43 46 344.714290 $24626.3700 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 15 16 126.107142 $9009.0900 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 7.142857 $510.2900 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 56 57 428.321434 $30599.2700 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 0.857143 $61.2300 $71.4400
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Subtotal (Total Children Is Unduplicated) 144 196 1346.450011 $86623.5100 $64.3300
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Total 237 1395.738900 $88247.7400 $63.2300
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Number of Children (Unduplicated) With at Least One Authorization 174