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: 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 601 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 1.255556 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 1.255556 $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 3 3 3.000000 $154.2300 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 3.000000 $154.2300 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
SCREEN-T1023 SCREENING 17 17 17.000000 $850.0000 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 6 6 7.200000 $370.1500 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.4100 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 2 2 3.133333 $161.0800 $51.4100
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Subtotal (Total Children Is Unduplicated) 32 35 38.333333 $1946.7500 $50.7800
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 3 5.766666 $288.3300 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 103 121 347.023810 $17351.1900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 60 75 187.190472 $9359.5000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 38 43 101.866663 $5093.3200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 53 55 141.083334 $7054.1700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 147 152 838.847633 $41942.3500 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 2 2 5.600000 $280.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 25 25 83.985715 $6043.6000 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 3.900000 $280.6400 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 13 14 41.671430 $2400.2800 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 26 26 109.575004 $7885.0200 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 1 1 0.866667 $62.3700 $71.9600
PHY -97110HM PT SESSION BY PT ASST 4 4 19.326190 $1112.4200 $57.5600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 37 40 210.307143 $15133.6900 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 4.714286 $339.2400 $71.9600
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Subtotal (Total Children Is Unduplicated) 231 564 2101.725013 $114626.1100 $54.5400
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Total 601 2141.313902 $116572.8500 $54.4400
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Number of Children (Unduplicated) With at Least One Authorization 242