Summary Report for FSPSAs Ending During the Report Period Center: 51
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: 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 876 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
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 0.166667 $6.2000 $37.2100
SCONLY-SCONLY *SERVICE COORDINATION ONLY 5 6 22.707936 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 1.733333 $64.4800 $37.2000
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Subtotal (Total Children Is Unduplicated) 7 8 24.607936 $70.6800 $2.8700
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 2 2 1.500000 $75.0000 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 2 2 2.000000 $102.8200 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 65 67 78.000000 $4009.9800 $51.4100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 18 18 18.000000 $925.3800 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 3 3 3.000000 $154.2300 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 12 15 15.000000 $771.1500 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 3 3 3.000000 $154.2300 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 9 9 9.000000 $462.6900 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.4100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 5 6 6.000000 $308.4600 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.4100 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $51.4100 $51.4100
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Subtotal (Total Children Is Unduplicated) 124 135 145.500000 $7478.0400 $51.4000
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 0.750000 $37.5000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1 1 3.933333 $196.6700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 0.433333 $21.6700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 3.066667 $76.6700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 4 5 79.880951 $3994.0500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 152 198 3646.395234 $182319.8400 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 12 14 288.857141 $14442.8700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 156 220 4120.623811 $296520.1100 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 7 10 252.428570 $18164.7600 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 9 9 50.285715 $2896.4600 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 25 39 591.814287 $42586.9400 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 1 1 26.000000 $1870.9600 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 1 1 52.000000 $3741.9200 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 158 213 4130.571427 $297235.9500 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 14 17 260.066665 $18714.4100 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 2.714286 $195.3200 $71.9600
SPL -92508HA GROUP SPL SESSION PER CHILD 1 1 23.142857 $323.0700 $13.9600
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Subtotal (Total Children Is Unduplicated) 406 733 13532.964277 $883339.1600 $65.2700
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Total 876 13703.072213 $890887.8800 $65.0100
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Number of Children (Unduplicated) With at Least One Authorization 455