Summary Report for FSPSAs Ending During the Report Period Center: 57
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 3 3 2.400001 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 16 16 10.969841 $408.0800 $37.2000
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Subtotal (Total Children Is Unduplicated) 19 19 13.369842 $408.0800 $30.5200
Screening, Eval, and Assessment, Class # 02
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.177778 $3.9200 $22.0700
AUDE -V5010 ASSESSMENT FOR HEARING AID 8 9 9.000000 $407.8800 $45.3200
OCTF -97168 OT RE-EVAL EST PLAN CARE 24 24 6.517461 $335.0700 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 14 14 6.905556 $355.0200 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 17 17 5.989681 $307.9300 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 3 3 2.105556 $108.2500 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 27 29 14.499208 $745.4100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 9 9 2.966668 $152.5200 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 4 2.722222 $122.1200 $44.8600
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Subtotal (Total Children Is Unduplicated) 75 110 50.884130 $2538.1100 $49.8800
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 3 1.016667 $50.8400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 297 313 271.719044 $13585.9200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 42 44 58.638093 $2931.8900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 340 356 270.349204 $13517.4400 $50.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 2 2 17.714286 $442.8600 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 40 43 264.714282 $6617.8700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 463 488 3254.174604 $162708.6800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2 2 36.142857 $361.4300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 44 48 188.642864 $13574.7300 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 28 33 139.071433 $10007.5800 $71.9600
PHY -97110HM PT SESSION BY PT ASST 1 1 3.428571 $197.3500 $57.5600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 50 55 247.357148 $17799.8300 $71.9600
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 1 1 2.428571 $139.8900 $57.6000
TRAV -TRAVS Travel by mile 9 11 43.403174 $19.3100 $0.4400
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Subtotal (Total Children Is Unduplicated) 506 1400 4798.800798 $241955.6100 $50.4200
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Total 1529 4863.054770 $244901.8000 $50.3600
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Number of Children (Unduplicated) With at Least One Authorization 533