Summary Report for FSPSAs Ending During the Report Period Center: 04
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: 04-01-23 and 06-30-23 Date of Report: 07-25-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1576 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 38 39 25.657141 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 38 39 25.657141 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
OCTH -97165TL OT EVAL LOW COMPLEXITY 6 6 1.577779 $81.1200 $51.4100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 2 2 0.511111 $26.2800 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 6 7 1.338889 $68.8300 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 24 29 7.456350 $383.3400 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 0.383334 $19.7100 $51.4200
PSTH -97161TL PT EVAL LOW COMPLEXITY 1 1 0.372222 $19.1300 $51.4100
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 2 2 0.505556 $25.9900 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 3 4 0.922223 $47.4200 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 16 19 20.960316 $1077.5600 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 20 22 8.352380 $429.3900 $51.4100
SPCH -92521TLGT EVAL OF SPEECH FLUENCY 1 1 0.266667 $13.7100 $51.4200
SPCH -92522TL EVAL OF SPCH SOUND PROD 2 2 0.283333 $14.5600 $51.4000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 5 5 0.972221 $49.9800 $51.4000
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 2 0.222222 $11.4200 $51.4000
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.383333 $19.7100 $51.4100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 1 19.714286 $1013.5100 $51.4100
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Subtotal (Total Children Is Unduplicated) 63 106 64.222222 $3301.6600 $51.4100
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 24 60 15.611897 $780.5600 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 3 3 1.122222 $56.1100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 3 3.111110 $77.7800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 8 8 1.377777 $68.8900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 2 2.366666 $59.1700 $25.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.744444 $18.6100 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 6 6 2.879365 $143.9700 $50.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 2 2 1.857143 $46.4300 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 81 105 632.285713 $15807.1400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 121 124 690.285717 $34514.2600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 380 415 2698.285719 $134914.3000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 471 518 3272.057154 $39264.6800 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 3 4 15.285715 $1099.9600 $71.9600
OCCT -97530TL OT SESSION BY LICENSED OT 56 64 396.857142 $28557.7900 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 4 5 27.714287 $1994.3100 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 39 44 283.500001 $20400.6200 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 3 11.857143 $853.2400 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 54 63 316.785714 $22795.8600 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 4.857143 $349.5200 $71.9600
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Subtotal (Total Children Is Unduplicated) 599 1431 8378.842072 $301803.1700 $36.0200
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Total 1576 8468.721435 $305104.8300 $36.0300
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Number of Children (Unduplicated) With at Least One Authorization 632