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: 10-01-22 and 12-31-22 Date of Report: 01-23-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1529 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 35 36 14.766662 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 35 36 14.766662 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 2 8.000000 $388.0000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 3 4 1.616667 $90.7000 $56.1000
OCTH -97165 OT EVAL LOW COMPLEXITY 16 16 16.103969 $827.9100 $51.4100
OCTH -97165TL OT EVAL LOW COMPLEXITY 5 6 0.955556 $49.1300 $51.4100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 0.244444 $12.5600 $51.4000
OCTH -97167 OT EVAL HIGH COMPLEXITY 26 27 19.238887 $989.0600 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 0.211111 $10.8500 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 3 3 0.338889 $17.4200 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 7 7 0.950001 $48.8400 $51.4200
PSTH -97161TL PT EVAL LOW COMPLEXITY 2 2 0.316666 $16.2800 $51.4000
PSTH -97163 PT EVAL HIGH COMPLEXITY 12 14 3.088888 $158.8000 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 0.188889 $9.7100 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 7 8 10.288889 $528.9500 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 8 8 1.716667 $88.2600 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 8 8 1.466667 $75.4000 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 0.200000 $10.2800 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 4 4 1.100000 $49.3500 $44.8600
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Subtotal (Total Children Is Unduplicated) 76 114 66.026190 $3371.5000 $51.0600
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $231.6200 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 18 49 10.494449 $524.7500 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 2 3 1.022223 $51.1200 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 4 5 7.315079 $365.7500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 1.222223 $30.5600 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 3 3 2.384126 $119.2100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.255556 $6.3900 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 6 7 17.571427 $439.2900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 70 81 385.357145 $9633.9300 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 2 11.714285 $585.7200 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 397 417 2548.174624 $127408.6800 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 107 114 641.336517 $32066.8000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 490 529 3158.507966 $31585.0600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 42 43 260.857143 $18771.2800 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 15 15 87.124207 $5018.3500 $57.6000
OCCT -97530TL OT SESSION BY LICENSED OT 14 15 68.785713 $4949.8300 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 20 21 92.928573 $6687.1300 $71.9600
PHY -97110HM PT SESSION BY PT ASST 9 11 51.142858 $2943.7700 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 7 8 35.928572 $2585.4100 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 25 25 119.142858 $8573.5000 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 16 17 90.428569 $6507.2400 $71.9600
SPL -92508HA GROUP SPL SESSION PER CHILD 7 10 35.000000 $488.6000 $13.9600
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Subtotal (Total Children Is Unduplicated) 602 1379 7627.694113 $259573.9700 $34.0300
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Total 1529 7708.486965 $262945.4800 $34.1100
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Number of Children (Unduplicated) With at Least One Authorization 638