Summary Report for FSPSAs Initiated During the Report Period Center: 04
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: 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 1370 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 31 31 18.553969 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 31 31 18.553969 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 2 3.775397 $183.1100 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 4 4 2.411111 $135.2600 $56.1000
OCTH -97165 OT EVAL LOW COMPLEXITY 4 4 0.677778 $34.8500 $51.4100
OCTH -97165TL OT EVAL LOW COMPLEXITY 16 16 3.438888 $176.7900 $51.4100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 3 3 1.011111 $51.9800 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 6 6 2.250001 $115.6800 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 6 7 1.466667 $75.4000 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 0.783333 $40.2700 $51.4100
PSTH -97161TL PT EVAL LOW COMPLEXITY 8 8 1.661110 $85.3900 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 4 4 0.744444 $38.2700 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 3 4 0.911111 $46.8400 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 3 3 4.281746 $220.1300 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 13 14 13.846826 $711.8700 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 1 1 0.483333 $24.8500 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 7 8 2.899999 $149.0800 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 0.200000 $10.2800 $51.4100
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.455556 $20.4400 $44.8600
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Subtotal (Total Children Is Unduplicated) 57 89 41.298411 $2120.4800 $51.3500
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 31 82 20.853175 $1042.6600 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1 1 0.833333 $41.6700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 2 1.744444 $43.6100 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 7 7 6.716666 $335.8300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.700000 $42.5000 $25.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.044444 $1.1100 $24.9800
CONSF -CONSF CONSULT, SLP, FACE TO FACE 6 6 7.400000 $370.0000 $50.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 7 8 69.571428 $1739.2800 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 62 75 496.214293 $12405.3500 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 2.428571 $121.4300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 264 268 2428.571437 $121428.5100 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 176 181 1006.771428 $50338.5200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 420 439 3349.153180 $33491.5100 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 9 10 69.285715 $4985.7800 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 1 1 10.571429 $608.9100 $57.6000
OCCT -97530TL OT SESSION BY LICENSED OT 56 59 331.971833 $23888.6700 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 5 6 28.714287 $2066.2700 $71.9600
PHY -97110HM PT SESSION BY PT ASST 3 3 17.785715 $1023.7400 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 31 36 186.642862 $13430.7900 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 1 1 12.857143 $925.2000 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 7 7 55.142857 $3968.0900 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 46 50 279.642863 $20123.0600 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 6.571429 $472.8800 $71.9600
SPL -92508HA GROUP SPL SESSION PER CHILD 4 4 23.428572 $327.0600 $13.9600
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Subtotal (Total Children Is Unduplicated) 520 1250 8414.617104 $293222.4400 $34.8500
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Total 1370 8474.469484 $295342.9200 $34.8500
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Number of Children (Unduplicated) With at Least One Authorization 551