Summary Report for FSPSAs Ending During the Report Period Center: 52
This report shows the total number of units/fees for FSPSAs ending during the report period.
(i.e., end 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 ending 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 770 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 3 4 1.300000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 4 1.300000 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
OCTH -97165 OT EVAL LOW COMPLEXITY 4 4 4.000000 $205.6400 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 7 7 7.000000 $359.8700 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 5 5 5.000000 $257.0500 $51.4100
SCREEN-T1023 SCREENING 24 24 24.000000 $1200.0000 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 5 5 5.000000 $257.0500 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 4 4 4.000000 $205.6400 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.4100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 2.433333 $125.1000 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 0.714286 $37.8100 $52.9300
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Subtotal (Total Children Is Unduplicated) 51 55 54.147619 $2750.9700 $50.8100
EI Services, Class # 03
CONIF -CONIF CONSULT, ITDS FACE TO FACE 134 162 387.357137 $19367.8300 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 2 2 7.666666 $383.3300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 85 102 271.223812 $13561.2000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 37 40 126.966667 $6348.3400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 82 85 209.533334 $10476.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 4.366667 $109.1700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 3.000000 $150.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 169 177 812.914282 $40645.6700 $50.0000
INTR -T1013 INTERPRETER 1 1 1.000000 $50.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 34 34 145.519048 $10471.5600 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 2 3 8.866667 $638.0500 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 15 17 78.152382 $4501.5800 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 20 20 107.391668 $7727.8900 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 1 1 4.000000 $287.8400 $71.9600
PHY -97110HM PT SESSION BY PT ASST 2 2 7.647619 $440.2000 $57.5600
PHY -97110TLGTHM PT SESSION BY PT ASST 1 1 9.714286 $559.1600 $57.5600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 57 59 268.119048 $19293.8400 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 5.857143 $421.4800 $71.9600
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Subtotal (Total Children Is Unduplicated) 239 711 2459.296426 $135433.7800 $55.0700
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Total 770 2514.744045 $138184.7600 $54.9500
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Number of Children (Unduplicated) With at Least One Authorization 250