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: 10-01-23 and 12-31-23 Date of Report: 01-14-24 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1466 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 46 47 26.582536 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 46 47 26.582536 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
OCTH -97165TL OT EVAL LOW COMPLEXITY 2 2 0.416667 $21.4200 $51.4100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 2 2 0.633333 $32.5600 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 2 3 0.483334 $24.8500 $51.4200
OCTH -97167TL OT EVAL HIGH COMPLEXITY 31 33 10.116665 $520.0900 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 0.116667 $6.0000 $51.4200
PSTH -97163TL PT EVAL HIGH COMPLEXITY 25 27 6.333334 $325.6000 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 24 27 8.222218 $422.6800 $51.4100
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.500000 $25.7100 $51.4100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 1 12.857143 $660.9800 $51.4100
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Subtotal (Total Children Is Unduplicated) 58 97 39.679361 $2039.8900 $51.4100
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 22 57 10.100000 $505.0000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 3 3 1.977777 $98.8900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 4 4 4.336508 $216.8300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 1.688888 $84.4400 $50.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 1.000000 $25.0000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 75 95 467.285712 $11682.1500 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 269 279 2047.857147 $102392.8500 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 219 220 1393.285723 $69664.3000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 468 494 3381.077791 $40572.9300 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 4.500000 $323.8200 $71.9600
OCCT -97530TL OT SESSION BY LICENSED OT 58 67 335.285718 $24127.1600 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 2 2 6.071429 $436.9000 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 36 39 195.642857 $14078.4400 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 4.642857 $334.1000 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 46 56 246.142856 $17712.4600 $71.9600
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Subtotal (Total Children Is Unduplicated) 569 1322 8100.895263 $282255.2500 $34.8400
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Total 1466 8167.157160 $284295.1500 $34.8100
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Number of Children (Unduplicated) With at Least One Authorization 611