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: 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 1510 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 24 24 11.699999 $435.2400 $37.2000
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Subtotal (Total Children Is Unduplicated) 24 24 11.699999 $435.2400 $37.2000
Screening, Eval, and Assessment, Class # 02
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 1.000000 $15.8400 $15.8400
AUDE -V5010 ASSESSMENT FOR HEARING AID 9 9 9.000000 $407.8800 $45.3200
OCTF -97168 OT RE-EVAL EST PLAN CARE 16 16 6.088889 $313.0300 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 10 10 3.111111 $159.9400 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 0.438889 $22.5600 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 7 9 2.655554 $136.5100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 10 10 3.422222 $175.9400 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 32 35 14.922220 $767.1400 $51.4100
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Subtotal (Total Children Is Unduplicated) 57 92 41.638885 $2050.2500 $49.2400
EI Services, Class # 03
CONOF -CONOF CONSULT, OT, FACE TO FACE 321 333 248.274605 $12413.7300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 46 46 53.660319 $2683.0100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 361 374 251.390476 $12569.5300 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 40 43 300.142859 $7503.5600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 460 485 3307.538064 $165377.0800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 33 34 161.714285 $11636.9700 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 2.285714 $164.4800 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 23 25 128.928570 $9277.7000 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 43 45 189.214283 $13615.8500 $71.9600
TRAV -TRAVS Travel by mile 8 8 61.000000 $27.1500 $0.4500
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Subtotal (Total Children Is Unduplicated) 498 1394 4704.149175 $235269.0500 $50.0100
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Total 1510 4757.488059 $237754.5400 $49.9700
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Number of Children (Unduplicated) With at Least One Authorization 519