Summary Report for FSPSAs Ending During the Report Period Center: 04
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: 01-01-22 and 03-31-22 Date of Report: 04-16-22 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1592 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 37 37 23.549209 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 37 37 23.549209 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 0.266667 $12.9400 $48.5100
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 0.355555 $18.1500 $51.0400
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 0.572223 $29.2200 $51.0600
OCTH -97167 OT EVAL HIGH COMPLEXITY 46 47 33.934127 $1732.3400 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 0.544445 $27.8000 $51.0600
PSTH -97163 PT EVAL HIGH COMPLEXITY 28 30 7.594444 $387.6900 $51.0500
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 0.366667 $18.7200 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 0.033333 $1.7000 $51.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 11 12 2.288889 $116.8500 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.366667 $18.7200 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 0.105556 $5.3900 $51.0700
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 22 23 24.156349 $1076.1600 $44.5500
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Subtotal (Total Children Is Unduplicated) 80 123 70.584922 $3445.6700 $48.8200
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.022222 $5.1100 $229.7700
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 26 81 45.786514 $2289.3500 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 2 2 1.100000 $55.0000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 2 2 1.100000 $55.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.261111 $6.5300 $25.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.488889 $12.2200 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 0.857143 $21.4300 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 76 90 534.142864 $13353.5600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 489 537 3376.027772 $168801.3400 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 2 2 5.285714 $264.2900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 472 522 3261.227778 $32612.2700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 38 40 216.928571 $15497.3500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 37 40 238.857146 $13662.6000 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 26 31 170.913492 $12210.0700 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 4.785714 $341.8900 $71.4400
PHY -97110HM PT SESSION BY PT ASST 24 26 160.714289 $9186.4100 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 37 44 194.482541 $13893.8300 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 10 10 45.142857 $626.5800 $13.8800
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Subtotal (Total Children Is Unduplicated) 587 1432 8258.124617 $282894.8000 $34.2600
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Total 1592 8352.258748 $286340.4800 $34.2800
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Number of Children (Unduplicated) With at Least One Authorization 624