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: 01-01-23 and 03-31-23 Date of Report: 04-20-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1491 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 17 9.700000 $360.8400 $37.2000
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Subtotal (Total Children Is Unduplicated) 15 17 9.700000 $360.8400 $37.2000
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 8 8 8.000000 $362.5600 $45.3200
OCTF -97168 OT RE-EVAL EST PLAN CARE 15 15 6.550000 $336.7400 $51.4100
OCTF -97168TLGT OT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.4100 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.316667 $16.2800 $51.4200
OCTH -97167 OT EVAL HIGH COMPLEXITY 20 20 7.961111 $409.2800 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 0.161111 $8.2800 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 9 11 2.622222 $134.8100 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 3 3 0.566667 $29.1300 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 36 40 15.205559 $781.7400 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 0.405556 $20.8500 $51.4200
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Subtotal (Total Children Is Unduplicated) 73 103 43.788893 $2202.4900 $50.3000
EI Services, Class # 03
CONOF -CONOF CONSULT, OT, FACE TO FACE 303 311 221.334918 $11066.7400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 49 51 51.233335 $2561.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 336 347 202.533332 $10126.6800 $50.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 2.571429 $64.2900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 50 52 355.285716 $8882.1400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 437 461 2920.576188 $146028.8400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 48 50 210.571431 $15152.7000 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 10.571429 $760.7200 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 21 23 66.500001 $4785.3400 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 60 63 304.857144 $21937.5100 $71.9600
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 1 1 4.000000 $230.4000 $57.6000
TRAV -TRAVS Travel by mile 9 10 35.911111 $15.9800 $0.4400
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Subtotal (Total Children Is Unduplicated) 486 1371 4385.946034 $221613.0000 $50.5300
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Total 1491 4439.434927 $224176.3300 $50.5000
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Number of Children (Unduplicated) With at Least One Authorization 512