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: 10-01-23 and 12-31-23 Date of Report: 01-14-24 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 687 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 0.466667 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 0.466667 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 3 3 3.000000 $154.2300 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
SCREEN-T1023 SCREENING 28 28 28.000000 $1400.0000 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 4 4 4.000000 $205.6400 $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 0.600000 $30.8500 $51.4100
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Subtotal (Total Children Is Unduplicated) 42 42 41.600000 $2099.1800 $50.4600
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 1.000000 $50.0000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 118 149 370.185708 $18509.2600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 77 84 229.119041 $11455.9200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 45 52 151.099998 $7554.9900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 65 66 180.583327 $9029.1400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 4.390476 $109.7600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 172 175 764.866669 $38243.3100 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 4 4 13.561904 $678.1000 $50.0000
INTR -T1013 INTERPRETER 1 1 0.700000 $35.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 19 19 106.823813 $7687.0400 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 12.461904 $896.7600 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 6 6 19.228570 $1107.5600 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 28 29 84.030953 $6046.8600 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 2 2 5.166666 $371.7900 $71.9600
PHY -97110HM PT SESSION BY PT ASST 8 8 54.421429 $3132.5000 $57.5600
PHY -97110TLGT PT SESSION BY LICENSED PT 1 1 0.900000 $64.7600 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 38 40 153.223810 $11025.9800 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 8.285714 $596.2400 $71.9600
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Subtotal (Total Children Is Unduplicated) 251 644 2160.049982 $116594.9700 $53.9800
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Total 687 2202.116649 $118694.1400 $53.9000
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Number of Children (Unduplicated) With at Least One Authorization 260