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: 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 1144 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 13 13 11.693650 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 3 3 2.411111 $89.2100 $37.0000
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Subtotal (Total Children Is Unduplicated) 16 16 14.104761 $89.2100 $6.3200
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 1.000000 $23.5000 $23.5000
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 4.000000 $180.0000 $45.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 8 8 5.127778 $261.7700 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 12 12 11.866666 $605.7900 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 3 3 0.549999 $28.0700 $51.0400
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 0.527778 $26.9400 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 5 5 4.346824 $221.9000 $51.0500
SPCH -92521GT EVAL OF SPEECH FLUENCY 2 2 2.000000 $102.1000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 6 6 1.794445 $91.6100 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 5 5 2.855555 $127.2100 $44.5500
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Subtotal (Total Children Is Unduplicated) 32 48 34.069045 $1668.9000 $48.9900
EI Services, Class # 03
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 0.188889 $13.0100 $68.8600
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 3.000000 $690.0000 $230.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 257 261 267.124601 $13356.2100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.033333 $0.8300 $24.9800
CONPF -CONPF CONSULT, PT, FACE TO FACE 35 37 38.257141 $1912.8600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 298 304 271.230949 $13561.5200 $50.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 2 2 15.571428 $389.2900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 14 14 168.857141 $4221.4300 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 16.285714 $814.2900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 391 405 2744.228536 $137211.5500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 9 9 85.857143 $858.5700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 14 14 100.703174 $7194.2400 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 7.571429 $433.0800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 6 6 18.603175 $1329.0100 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 19 19 150.428571 $10746.6300 $71.4400
TRAV -TRAVS Travel by mile 2 2 9.933333 $4.4200 $0.4400
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Subtotal (Total Children Is Unduplicated) 407 1080 3897.874557 $192736.9300 $49.4500
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Total 1144 3946.048363 $194495.0400 $49.2900
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Number of Children (Unduplicated) With at Least One Authorization 417