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 763 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 3 4 1.522222 $56.6300 $37.2000
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Subtotal (Total Children Is Unduplicated) 3 4 1.522222 $56.6300 $37.2000
Screening, Eval, and Assessment, Class # 02
OCTF -97168 OT RE-EVAL EST PLAN CARE 2 2 1.411111 $72.5400 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 0.266667 $13.7100 $51.4200
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 0.027778 $1.4300 $51.4500
SPCH -92521 EVAL OF SPEECH FLUENCY 2 4 2.311111 $118.8100 $51.4100
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Subtotal (Total Children Is Unduplicated) 5 8 4.016667 $206.5000 $51.4100
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 -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 11.142857 $278.5700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 22 25 124.215871 $6210.8000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 5.571429 $400.9200 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 2 2 11.857143 $853.2400 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 3 36.571428 $2631.6900 $71.9600
TRAV -TRAVS Travel by mile 9 10 35.911111 $15.9800 $0.4400
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Subtotal (Total Children Is Unduplicated) 412 751 700.371424 $34146.2800 $48.7500
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Total 763 705.910313 $34409.4000 $48.7400
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Number of Children (Unduplicated) With at Least One Authorization 417