Summary Report for FSPSAs Initiated During the Report Period Center: 04
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 1669 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 53 53 25.499997 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 53 53 25.499997 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.027778 $1.7200 $61.7600
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 0.194444 $11.3000 $58.1000
OCTH -97167TL OT EVAL HIGH COMPLEXITY 54 59 12.750000 $740.9000 $58.1100
PSTH -97161TL PT EVAL LOW COMPLEXITY 1 1 0.450000 $26.1500 $58.1100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 21 23 5.527777 $321.2100 $58.1100
SPCH -92521TL EVAL OF SPEECH FLUENCY 36 39 8.438887 $490.3700 $58.1100
SPCH -92522TL EVAL OF SPCH SOUND PROD 2 3 0.344445 $20.0200 $58.1200
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Subtotal (Total Children Is Unduplicated) 76 127 27.733331 $1611.6700 $58.1100
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 3.000000 $694.8600 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 29 69 13.016663 $650.8200 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 6 6 2.844446 $142.2300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 7 7 2.698413 $134.9300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 0.455556 $22.7800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 6 6 1.100001 $55.0100 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 117 173 761.571446 $20562.4300 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 475 496 3199.571471 $172776.8300 $54.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 471 500 3283.630203 $39403.5600 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 0.142857 $11.6200 $81.3400
OCCT -97530TL OT SESSION BY LICENSED OT 84 92 395.714288 $32179.4600 $81.3200
OCCT -97530TLGO OT SESSION BY LICENSED OT 1 1 3.500000 $284.6200 $81.3200
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 12.857143 $1045.5400 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 2 2 8.571429 $697.0300 $81.3200
PHY -97110TL PT SESSION BY LICENSED PT 44 49 221.642855 $18023.9700 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 73 82 283.000001 $23013.5200 $81.3200
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Subtotal (Total Children Is Unduplicated) 592 1489 8193.316772 $309699.2000 $37.8000
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Total 1669 8246.550100 $311310.8700 $37.7500
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Number of Children (Unduplicated) With at Least One Authorization 636