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: 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 6816 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
TCM -T1017TL TARGETED CASE MANAGEMENT 87 94 105.310316 $3917.5400 $37.2000
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Subtotal (Total Children Is Unduplicated) 87 94 105.310316 $3917.5400 $37.2000
Screening, Eval, and Assessment, Class # 02
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 1.000000 $15.8400 $15.8400
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.000000 $28.9200 $28.9200
AUDE -V5010 ASSESSMENT FOR HEARING AID 37 42 42.000000 $1903.4400 $45.3200
OCTF -97168 OT RE-EVAL EST PLAN CARE 48 71 49.812701 $2560.8800 $51.4100
OCTF -97168TLGT OT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.4100 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.894444 $45.9800 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 70 70 50.861111 $2614.7700 $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 28 47 35.430159 $1821.4700 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 32 33 59.994444 $3084.3100 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 2 2 1.461111 $75.1200 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 0.222222 $11.4200 $51.4000
SPCH -92521 EVAL OF SPEECH FLUENCY 99 144 97.538888 $5014.4700 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 11 14 9.072223 $466.4100 $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) 203 434 355.248414 $17949.4800 $50.5300
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 1 3 1.766667 $88.3400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 989 1391 2605.317434 $130265.7800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 126 191 553.003174 $27650.1500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1103 1533 2496.444419 $124822.1100 $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 131 300 3153.242835 $78831.0600 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 2 14.000000 $700.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1401 2049 32909.430104 $1645471.8000 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 3.571429 $178.5700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 127 269 1970.357139 $141787.0100 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 2 37.142857 $2672.8000 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 3 5 5.490475 $316.2500 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 71 159 1275.714284 $91800.4400 $71.9600
PHY -97110HM PT SESSION BY PT ASST 2 2 7.785714 $448.1400 $57.5600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 158 331 2464.428563 $177340.4600 $71.9600
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 1 1 14.714286 $847.5400 $57.6000
TRAV -TRAVS Travel by mile 31 44 612.290476 $272.4700 $0.4400
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Subtotal (Total Children Is Unduplicated) 1478 6288 48181.985569 $2424950.0600 $50.3300
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Total 6816 48642.544299 $2446817.0800 $50.3000
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Number of Children (Unduplicated) With at Least One Authorization 1510