Summary Report for FSPSAs Initiated During the Report Period Center: 51
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: 10-01-21 and 12-31-21 Date of Report: 02-04-22 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 186 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 4 4 4.833333 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 4 4 4.833333 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 1 1 1.000000 $50.0000 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.0500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 3 3 3.000000 $153.1500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 15 15 15.000000 $765.7500 $51.0500
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 6 6 6.000000 $306.3000 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 2.000000 $102.1000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.0500 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 1.000000 $51.0500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $44.5500 $44.5500
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Subtotal (Total Children Is Unduplicated) 31 33 33.000000 $1677.1000 $50.8200
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 0.750000 $37.5000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 63 65 604.985710 $30249.3000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 30 31 207.428572 $14818.7000 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 10 10 63.785714 $4556.8600 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 38 39 300.438090 $21463.3200 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 3 3 19.142857 $265.7000 $13.8800
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Subtotal (Total Children Is Unduplicated) 123 149 1196.530943 $71391.3800 $59.6700
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Total 186 1234.364276 $73068.4800 $59.2000
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Number of Children (Unduplicated) With at Least One Authorization 141