Summary Report for FSPSAs Ending During the Report Period Center: 57
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 1496 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 2 2 5.142857 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 13 13 5.733332 $212.1300 $37.0000
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Subtotal (Total Children Is Unduplicated) 15 15 10.876189 $212.1300 $19.5000
Screening, Eval, and Assessment, Class # 02
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 1.000000 $51.0700 $51.0700
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 1.344444 $60.5000 $45.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 2 3 2.455556 $125.3600 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 19 19 9.848412 $502.7600 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 3 2.361111 $120.5300 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 8 8 4.750000 $242.4900 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 17 17 9.437301 $481.7700 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 6 8 5.750001 $256.1700 $44.5500
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Subtotal (Total Children Is Unduplicated) 33 61 36.946825 $1840.6500 $49.8200
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 2 0.511112 $25.5600 $50.0100
CONOF -CONOF CONSULT, OT, FACE TO FACE 210 216 241.533327 $12076.6700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 30 30 41.550794 $2077.5400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 257 261 240.455547 $12022.7500 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 33 35 204.714286 $5117.8600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 384 392 2632.492070 $131624.6200 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 2 2 10.428571 $521.4300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 385 396 2592.093659 $25920.9400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 32 33 132.214288 $9445.3900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 2 2 4.142857 $236.9700 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 11 11 36.357145 $2597.3400 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 1.500000 $107.1600 $71.4400
PHY -97110HM PT SESSION BY PT ASST 4 5 30.428572 $1739.2900 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 33 34 117.428573 $8389.0900 $71.4400
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Subtotal (Total Children Is Unduplicated) 419 1420 6285.850801 $211902.6000 $33.7100
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Total 1496 6333.673815 $213955.3800 $33.7800
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Number of Children (Unduplicated) With at Least One Authorization 441