Summary Report for FSPSAs Initiated During the Report Period Center: 52
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 801 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 3 3 2.255555 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 2.255555 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 3 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 3 3 3.000000 $153.1500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 5 5 5.000000 $255.2500 $51.0500
SCREEN-T1023 SCREENING 23 23 23.000000 $1150.0000 $50.0000
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 7 8 8.000000 $408.4000 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 5 5 5.000000 $222.7500 $44.5500
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Subtotal (Total Children Is Unduplicated) 47 52 52.000000 $2594.8000 $49.9000
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 2 1.866667 $93.3400 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 151 166 338.904758 $16945.2200 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 86 94 227.366663 $11368.3200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 36 40 93.033333 $4651.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 103 107 220.838095 $11041.9000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 1.000000 $25.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 180 192 994.995242 $49749.7900 $50.0000
INTR -T1013 INTERPRETER 1 1 0.857143 $42.8600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 24 25 123.719048 $8838.4900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 7 7 44.447619 $2542.4000 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 2 2 12.876190 $736.5200 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 20 21 136.545239 $9754.7900 $71.4400
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 1 1 5.678571 $324.5900 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 77 84 403.307146 $28812.2800 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 2 2 2.738096 $38.0000 $13.8800
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Subtotal (Total Children Is Unduplicated) 293 746 2608.173810 $144965.1400 $55.5800
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Total 801 2662.429365 $147559.9400 $55.4200
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Number of Children (Unduplicated) With at Least One Authorization 308