Summary Report for FSPSAs Initiated During the Report Period Center: 57
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 1442 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
TCM -T1017TL TARGETED CASE MANAGEMENT 15 15 11.855555 $441.0200 $37.2000
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Subtotal (Total Children Is Unduplicated) 15 15 11.855555 $441.0200 $37.2000
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 8 9 9.000000 $407.8800 $45.3200
OCTF -97168 OT RE-EVAL EST PLAN CARE 18 18 5.683336 $292.1900 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 20 20 9.544446 $490.6900 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 10 10 4.833334 $248.4900 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 0.288889 $14.8500 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 31 32 14.300002 $735.1700 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 1.655555 $85.1100 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $44.8600 $44.8600
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Subtotal (Total Children Is Unduplicated) 66 96 47.305562 $2370.6500 $50.1100
EI Services, Class # 03
CONOF -CONOF CONSULT, OT, FACE TO FACE 307 316 235.611106 $11780.5400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 40 42 44.984130 $2249.2200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 346 357 236.452377 $11822.6000 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 34 34 236.428572 $5910.7100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 447 467 3359.555559 $167977.7100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 39 39 156.257143 $11244.2500 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 17 17 91.571430 $6589.4700 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 45 46 199.896824 $14384.5800 $71.9600
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 1 1 10.714286 $617.1400 $57.6000
TRAV -TRAVS Travel by mile 11 12 54.798413 $24.3900 $0.4400
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Subtotal (Total Children Is Unduplicated) 475 1331 4626.269840 $232600.6100 $50.2800
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Total 1442 4685.430957 $235412.2800 $50.2400
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Number of Children (Unduplicated) With at Least One Authorization 484