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: 01-01-23 and 03-31-23 Date of Report: 04-20-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 752 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 3 0.622222 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 0.622222 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 2 2 2.000000 $100.0000 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 3 3 3.000000 $154.2300 $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 1 1 1.000000 $51.4100 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 4 4.000000 $205.6400 $51.4100
SCREEN-T1023 SCREENING 37 37 37.000000 $1850.0000 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 9 9 9.000000 $462.6900 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 1 2 2.000000 $102.8200 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.4100 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 3.571429 $189.0300 $52.9300
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Subtotal (Total Children Is Unduplicated) 58 65 67.571429 $3424.2800 $50.6800
EI Services, Class # 03
CONIF -CONIF CONSULT, ITDS FACE TO FACE 130 151 340.216669 $17010.8500 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 2.166667 $108.3400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 77 84 195.466671 $9773.3600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 38 45 121.766666 $6088.3300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 65 65 135.166670 $6758.3500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 5.833333 $145.8300 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 0.533333 $13.3300 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 0.704762 $35.2400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 201 205 984.947630 $49247.3400 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 3 3 12.438095 $621.9000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 22 25 114.483333 $8238.2300 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 4 4 29.999999 $1728.0000 $57.6000
OCCT -97530TLGTHM OT SESSION BY OT ASST 1 1 2.400000 $138.2400 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 31 32 133.669047 $9618.8200 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 1 1 1.233333 $88.7500 $71.9600
PHY -97110HM PT SESSION BY PT ASST 8 9 41.164285 $2369.4200 $57.5600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 47 50 179.840478 $12941.3200 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 3.571429 $257.0000 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 4.200000 $302.2300 $71.9600
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Subtotal (Total Children Is Unduplicated) 289 684 2309.802400 $125484.8700 $54.3300
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Total 752 2377.996051 $128909.1500 $54.2100
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Number of Children (Unduplicated) With at Least One Authorization 312