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 651 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
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Subtotal (Total Children Is Unduplicated) 13 13 11.693650 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 0.733333 $37.4300 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 5 5 1.483333 $75.7200 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 0.527778 $26.9400 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 3 3 0.899999 $45.9400 $51.0400
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 1.166667 $59.5600 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.483333 $21.5300 $44.5500
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Subtotal (Total Children Is Unduplicated) 9 17 5.294443 $267.1300 $50.4600
EI Services, Class # 03
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
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 16.285714 $814.2900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 6 6 26.311111 $1315.5600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 9 9 85.857143 $858.5700 $10.0000
TRAV -TRAVS Travel by mile 2 2 9.933333 $4.4200 $0.4400
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Subtotal (Total Children Is Unduplicated) 361 621 715.033325 $31824.2500 $44.5100
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Total 651 732.021418 $32091.3800 $43.8400
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Number of Children (Unduplicated) With at Least One Authorization 375