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: 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 1463 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 16 16 7.088890 $263.7100 $37.2000
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Subtotal (Total Children Is Unduplicated) 16 16 7.088890 $263.7100 $37.2000
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 8 8 7.966667 $361.0500 $45.3200
OCTF -97168 OT RE-EVAL EST PLAN CARE 10 11 2.588888 $133.0900 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 10 10 6.299207 $323.8400 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 10 11 5.205554 $267.6100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 5 5 2.692858 $138.4500 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 22 23 9.444444 $485.5400 $51.4100
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Subtotal (Total Children Is Unduplicated) 51 68 34.197618 $1709.5800 $49.9900
EI Services, Class # 03
CONOF -CONOF CONSULT, OT, FACE TO FACE 305 313 216.741266 $10837.0600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 31 31 42.969838 $2148.4800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 335 346 198.411103 $9920.5300 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 60 66 411.635717 $10290.8900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 427 446 2778.353975 $138917.6900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 52 59 208.571427 $15008.8100 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 1 1 7.428571 $427.8900 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 29 33 128.500001 $9246.8500 $71.9600
PHY -97110HM PT SESSION BY PT ASST 5 6 54.000000 $3108.2400 $57.5600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 61 68 263.785714 $18982.0200 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 2 7.285715 $419.6600 $57.6000
TRAV -TRAVS Travel by mile 7 8 50.928570 $22.6600 $0.4400
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Subtotal (Total Children Is Unduplicated) 488 1379 4368.611897 $219330.7600 $50.2100
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Total 1463 4409.898405 $221304.0400 $50.1800
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Number of Children (Unduplicated) With at Least One Authorization 511