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: 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 564 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
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.3200 $45.3200
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 0.338889 $17.4200 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 4 4 1.438889 $73.9700 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 0.116667 $6.0000 $51.4200
PSTH -97163 PT EVAL HIGH COMPLEXITY 4 4 2.988889 $153.6600 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 8 9 4.061111 $208.7800 $51.4100
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Subtotal (Total Children Is Unduplicated) 13 20 9.944445 $505.1600 $50.8000
EI Services, Class # 03
CONOF -CONOF CONSULT, OT, FACE TO FACE 198 202 171.058736 $8552.9700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 29 29 35.790475 $1789.5200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 278 284 215.915881 $10795.8300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 17 18 138.847622 $6942.3700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 8.714286 $627.0800 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 1 1 3.000000 $215.8800 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 10.857143 $781.2800 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 2 9.428572 $543.0800 $57.6000
TRAV -TRAVS Travel by mile 6 6 24.142857 $10.7400 $0.4500
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Subtotal (Total Children Is Unduplicated) 339 544 617.755572 $30258.7400 $48.9800
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Total 564 627.700017 $30763.8900 $49.0100
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Number of Children (Unduplicated) With at Least One Authorization 344