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 3379 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 11 13 15.155555 $563.7800 $37.2000
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Subtotal (Total Children Is Unduplicated) 11 13 15.155555 $563.7800 $37.2000
Screening, Eval, and Assessment, Class # 02
OCTF -97168 OT RE-EVAL EST PLAN CARE 6 8 5.255557 $270.2000 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 10 10 4.772223 $245.3400 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 0.222222 $11.4200 $51.4000
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 3 1.872223 $96.2500 $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 17 22 10.238890 $526.3900 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 2.077778 $106.8200 $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) 27 51 30.063496 $1545.5800 $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 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 -T1027TTSC EI GROUP SESSION BY EI PROF 12 12 61.999998 $1550.0000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 2 14.000000 $700.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 62 102 1562.573016 $78128.6500 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 7 8 35.500000 $2554.5900 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 5 6 70.642856 $5083.4700 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 18 22 156.071428 $11230.9300 $71.9600
TRAV -TRAVS Travel by mile 31 44 612.290476 $272.4700 $0.4400
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Subtotal (Total Children Is Unduplicated) 1313 3315 8170.609468 $382396.4600 $46.8000
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Total 3379 8215.828519 $384505.8300 $46.8000
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Number of Children (Unduplicated) With at Least One Authorization 1320