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: 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 6562 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 9 9 22.468255 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 69 78 89.947616 $3346.0400 $37.2000
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Subtotal (Total Children Is Unduplicated) 78 87 112.415871 $3346.0400 $29.7600
Screening, Eval, and Assessment, Class # 02
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 1.000000 $15.8400 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 3 3 3.000000 $58.5300 $19.5100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.200000 $26.4800 $22.0700
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.000000 $28.9200 $28.9200
AUDE -V5010 ASSESSMENT FOR HEARING AID 32 36 36.000000 $1631.5200 $45.3200
OCTF -97168 OT RE-EVAL EST PLAN CARE 65 90 59.157146 $3041.2800 $51.4100
OCTF -97168TLGT OT RE-EVAL EST PLAN CARE 1 2 2.000000 $102.8200 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 4 4 1.755555 $90.2500 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 71 71 47.633334 $2448.8300 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 0.816667 $41.9900 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 3 3 2.144444 $110.2400 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 36 50 34.552380 $1776.3300 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 35 36 61.516667 $3162.5700 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 0.461111 $23.7100 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 0.222222 $11.4200 $51.4000
SPCH -92521 EVAL OF SPEECH FLUENCY 96 137 104.569842 $5375.9400 $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 25 36 17.361113 $892.5400 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 5 6 4.455557 $229.0700 $51.4100
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Subtotal (Total Children Is Unduplicated) 219 482 380.846038 $19171.1100 $50.3400
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.000000 $50.0000 $50.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 0.855556 $59.3400 $69.3500
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 4 2.050000 $102.5000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 868 1281 2618.152369 $130907.6200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 122 189 567.538891 $28376.9500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 997 1430 2469.899993 $123494.9700 $50.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 4 4 56.285713 $1407.1500 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 143 297 3252.099999 $81302.5100 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 4 21.995238 $1099.7700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1289 1954 32167.698434 $1608384.8800 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 2 10.285715 $514.2900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 12 12 132.714286 $1592.5700 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 141 278 2066.000003 $148669.3200 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 21.857143 $1572.8400 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 4 8 13.347618 $768.8200 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 71 153 1249.857144 $89939.6900 $71.9600
PHY -97110HM PT SESSION BY PT ASST 4 6 33.571429 $1932.3600 $57.5600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 168 326 2385.879363 $171687.8700 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 3.285714 $189.2600 $57.6000
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 1 2 30.285715 $1744.4600 $57.6000
TRAV -TRAVS Travel by mile 28 39 515.434920 $229.3700 $0.4400
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Subtotal (Total Children Is Unduplicated) 1347 5993 47620.095243 $2394026.4900 $50.2700
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Total 6562 48113.357152 $2416543.6400 $50.2300
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Number of Children (Unduplicated) With at Least One Authorization 1380