Summary Report for FSPSAs Initiated During the Report Period Center: 52
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: 01-01-22 and 03-31-22 Date of Report: 04-16-22 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 864 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 2 2 1.688888 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 1.688888 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 2 2 2.000000 $100.0000 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 9 9 9.000000 $459.4500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 3.000000 $153.1500 $51.0500
SCREEN-T1023 SCREENING 33 34 41.428571 $2071.4300 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.0500 $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 7 7 7.666667 $391.3900 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 5 5 5.000000 $222.7500 $44.5500
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 3 3 9.819047 $516.1800 $52.5700
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Subtotal (Total Children Is Unduplicated) 58 69 83.914285 $4220.6500 $50.3000
EI Services, Class # 03
CONIF -CONIF CONSULT, ITDS FACE TO FACE 166 189 430.033338 $21501.6900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 0.750000 $18.7500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 86 97 235.000001 $11750.0100 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 47 52 134.799998 $6739.9900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 117 121 269.233338 $13461.6900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 179 187 943.219037 $47160.9900 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 0.571429 $28.5700 $50.0000
INTR -T1013 INTERPRETER 1 1 0.533333 $26.6700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 24 25 92.928572 $6638.8300 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 8 9 24.438095 $1397.8500 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 2 2 14.857143 $849.8300 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 30 30 131.023810 $9360.3400 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 29.142857 $1665.8100 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 2 2 14.085714 $805.1400 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 67 71 375.245231 $26807.5500 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 0.142857 $10.2100 $71.4600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 0.533333 $38.1000 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 1 1 5.666667 $78.6500 $13.8800
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Subtotal (Total Children Is Unduplicated) 285 793 2702.204753 $148340.6500 $54.9000
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Total 864 2787.807926 $152561.3000 $54.7200
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Number of Children (Unduplicated) With at Least One Authorization 304