Summary Report for FSPSAs Initiated During the Report Period Center: 57
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 1126 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 3.044444 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.022222 $0.8200 $36.9600
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Subtotal (Total Children Is Unduplicated) 3 3 3.066666 $0.8200 $0.2700
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 1.344444 $60.5000 $45.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 2 2 1.055556 $53.8900 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 19 19 16.680951 $851.5500 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 3 2.394444 $122.2300 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 5 5 1.944445 $99.2700 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 18 18 18.975396 $968.6900 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 10 10 10.683333 $475.9400 $44.5500
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Subtotal (Total Children Is Unduplicated) 33 59 53.078569 $2632.0700 $49.5900
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 4 1.411112 $70.5600 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1 1 0.677778 $33.8900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 179 181 212.746821 $10637.3300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.522222 $13.0600 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 27 27 42.657144 $2132.8600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 209 211 204.516666 $10225.8200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.500000 $12.5000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 29 31 228.571428 $5714.2900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 316 320 2412.020644 $120601.0600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 208 210 1809.492069 $18094.9200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 28 28 140.142858 $10011.8200 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 2 2 8.357143 $478.0300 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 10 11 48.785716 $3485.2400 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 10.857143 $620.6000 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 29 30 153.285714 $10950.7400 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 3 3 7.214286 $412.6600 $57.2000
SPL -92508HA GROUP SPL SESSION PER CHILD 1 1 6.142857 $85.2600 $13.8800
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Subtotal (Total Children Is Unduplicated) 336 1064 5287.901601 $193580.6400 $36.6100
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Total 1126 5344.046836 $196213.5300 $36.7200
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Number of Children (Unduplicated) With at Least One Authorization 341