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 656 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
AUD -92626 EVAL OF AUD REHAB STATUS 1 2 0.366667 $20.5700 $56.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 2 2 0.638889 $32.8500 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 0.138889 $7.1400 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 0.150000 $7.7100 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 0.188889 $9.7100 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 9.000000 $462.6900 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.161111 $8.2800 $51.4100
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Subtotal (Total Children Is Unduplicated) 6 9 10.644445 $548.9500 $51.5700
EI Services, Class # 03
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 2 2 0.455555 $22.7800 $49.9900
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.255556 $6.3900 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 6.285714 $157.1400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 11 12 85.571429 $4278.5800 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 5 5 27.285715 $1364.2800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 490 529 3158.507966 $31585.0600 $10.0000
OCCT -97530HM OT SESSION BY OT ASST 1 1 12.571429 $724.1100 $57.6000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 4.142857 $298.1200 $71.9600
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Subtotal (Total Children Is Unduplicated) 516 611 3315.130195 $39408.6300 $11.8900
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Total 656 3340.541302 $39957.5800 $11.9600
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Number of Children (Unduplicated) With at Least One Authorization 553