Summary Report for FSPSAs Initiated During the Report Period Center: 03
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: 07-01-24 and 09-30-24 Date of Report: 04-06-25 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 667 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 39 39 19.580953 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 39 39 19.580953 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 3 3 2.111111 $102.3900 $48.5000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.000000 $31.8100 $31.8100
OCTH -97167 OT EVAL HIGH COMPLEXITY 20 22 9.472221 $550.4200 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 25 27 13.694445 $795.7900 $58.1100
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 1.000000 $58.1100 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 33 34 19.933333 $1158.3200 $58.1100
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Subtotal (Total Children Is Unduplicated) 80 90 49.211110 $2813.0600 $57.1600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 1.577778 $7889.0000 $5000.0700
CONIF -CONIF CONSULT, ITDS FACE TO FACE 8 8 10.588889 $529.4500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 24 26 35.844445 $1792.2300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 27 30 37.627776 $1881.3800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 45 54 46.838891 $2341.9600 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 3.266667 $163.3400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 224 306 1204.761916 $65057.1400 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 4.000000 $216.0000 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 22 29 109.219047 $8881.6900 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 32 40 177.661907 $14447.4600 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 33 40 164.466668 $13374.4200 $81.3200
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Subtotal (Total Children Is Unduplicated) 311 538 1795.853984 $116574.0500 $64.9100
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Total 667 1864.646047 $119387.1100 $64.0300
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Number of Children (Unduplicated) With at Least One Authorization 352