Summary Report for FSPSAs Initiated During the Report Period Center: 04
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: 07-01-22 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 2683 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 157 178 279.649203 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 157 178 279.649203 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 0.466667 $22.6400 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.161111 $9.0400 $56.1000
OCTH -97165 OT EVAL LOW COMPLEXITY 1 2 0.616667 $31.7000 $51.4100
OCTH -97165TL OT EVAL LOW COMPLEXITY 1 1 0.900000 $46.2700 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 2 2 1.550000 $79.6900 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 3 4 2.661112 $136.8100 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.005556 $51.7000 $51.4100
PSTH -97161TL PT EVAL LOW COMPLEXITY 1 1 0.705556 $36.2700 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 2 1.172222 $60.2600 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 6 6 2.433334 $125.1000 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 5.189682 $266.8000 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 4 5 3.677779 $189.0800 $51.4100
SPCH -92521TLGT EVAL OF SPEECH FLUENCY 1 1 0.761111 $39.1300 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 1 1 1.005556 $51.7000 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 2 1.127778 $57.9800 $51.4100
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Subtotal (Total Children Is Unduplicated) 17 32 23.434131 $1204.1700 $51.3900
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.000000 $50.0000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 57 235 151.497629 $7574.9300 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 12 15 26.632541 $1331.6300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 3 4 10.866666 $271.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 30 36 85.841267 $4292.0500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 4 5 10.499999 $262.5000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 0.355556 $17.7800 $50.0100
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.788889 $44.7200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 11 12 17.398411 $869.9200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 0.355555 $8.8900 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 6.285714 $157.1400 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 4 51.428572 $1285.7100 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 25.857143 $1292.8600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 18 23 485.285713 $24264.2800 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 36 46 841.428574 $42071.4200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1441 2062 35175.426139 $422105.1800 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 3 35.428572 $2549.4300 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 1 1 20.285714 $1168.4600 $57.6000
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 22.571429 $1624.2400 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 3 4 112.000000 $8059.5100 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 6 6 40.500000 $2914.3900 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 3 28.142857 $2025.1600 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 4 5 78.071428 $5618.0300 $71.9600
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Subtotal (Total Children Is Unduplicated) 1512 2473 37228.948368 $529859.8700 $14.2300
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Total 2683 37532.031702 $531064.0400 $14.1500
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Number of Children (Unduplicated) With at Least One Authorization 1604