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 3227 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 12 16 22.599999 $840.7200 $37.2000
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Subtotal (Total Children Is Unduplicated) 21 25 45.068254 $840.7200 $18.6500
Screening, Eval, and Assessment, Class # 02
OCTF -97168 OT RE-EVAL EST PLAN CARE 8 11 7.761111 $399.0000 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.266667 $13.7100 $51.4200
OCTH -97167 OT EVAL HIGH COMPLEXITY 11 11 3.972223 $204.2200 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 0.222222 $11.4200 $51.4000
PSTF -97164 PT RE-EVAL EST PLAN CARE 5 5 3.066666 $157.6500 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 4.402381 $226.3300 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 0.222222 $11.4200 $51.4000
SPCH -92521 EVAL OF SPEECH FLUENCY 18 25 10.838889 $557.2300 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 6 6 3.311111 $170.2200 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 2 2.000000 $102.8200 $51.4100
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Subtotal (Total Children Is Unduplicated) 32 65 36.063492 $1854.0200 $51.4100
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 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 -T1027TTSC EI GROUP SESSION BY EI PROF 11 13 80.142858 $2003.5700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 2 14.000000 $700.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 74 119 1814.176193 $90708.8000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 12 12 132.714286 $1592.5700 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 9 14 76.571430 $5510.0600 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 2 2 5.571429 $320.9100 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 3 3 56.857142 $4091.4400 $71.9600
PHY -97110HM PT SESSION BY PT ASST 3 3 23.285715 $1340.3200 $57.5600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 17 25 178.428573 $12839.7100 $71.9600
TRAV -TRAVS Travel by mile 28 39 515.434920 $229.3700 $0.4400
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Subtotal (Total Children Is Unduplicated) 1201 3137 8555.823799 $402268.7900 $47.0200
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Total 3227 8636.955545 $404963.5300 $46.8900
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Number of Children (Unduplicated) With at Least One Authorization 1217