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 786 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 6 6 4.599999 $171.1200 $37.2000
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Subtotal (Total Children Is Unduplicated) 9 9 7.000000 $171.1200 $24.4500
Screening, Eval, and Assessment, Class # 02
OCTF -97168 OT RE-EVAL EST PLAN CARE 2 2 0.738889 $37.9900 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 3 3 1.027778 $52.8400 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.4100 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 4 4 0.844445 $43.4200 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 2 2.000000 $89.7200 $44.8600
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Subtotal (Total Children Is Unduplicated) 7 12 5.611112 $275.3700 $49.0800
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
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 25 29 200.925400 $10046.2600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2 2 36.142857 $361.4300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 8.571429 $616.8000 $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 4 5 36.785714 $2647.1100 $71.9600
TRAV -TRAVS Travel by mile 9 11 43.403174 $19.3100 $0.4400
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Subtotal (Total Children Is Unduplicated) 426 765 930.980153 $43974.3400 $47.2300
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Total 786 943.591265 $44420.8300 $47.0800
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Number of Children (Unduplicated) With at Least One Authorization 437