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: 10-01-22 and 12-31-22 Date of Report: 01-23-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 152 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 1 1 4.285714 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 1.733333 $64.4800 $37.2000
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Subtotal (Total Children Is Unduplicated) 2 2 6.019047 $64.4800 $10.7100
Screening, Eval, and Assessment, Class # 02
OCTH -97165 OT EVAL LOW COMPLEXITY 11 11 11.000000 $565.5100 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 3 3 3.000000 $154.2300 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 8 8 8.000000 $411.2800 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 6 6 6.000000 $308.4600 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 2.000000 $102.8200 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.4100 $51.4100
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Subtotal (Total Children Is Unduplicated) 34 34 34.000000 $1747.9400 $51.4100
EI Services, Class # 03
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 3 16.719047 $835.9500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 32 32 222.942853 $11147.1600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 3 4 37.571429 $1878.5700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 40 40 269.000001 $19357.2400 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 31.857143 $2292.4400 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 1 1 8.714286 $627.0800 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 32 32 249.714287 $17969.4300 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 10.619047 $764.1400 $71.9600
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Subtotal (Total Children Is Unduplicated) 101 116 847.138093 $54872.0100 $64.7700
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Total 152 887.157140 $56684.4300 $63.8900
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Number of Children (Unduplicated) With at Least One Authorization 118