Summary Report for FSPSAs Ending During the Report Period Center: 51
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: 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 295 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 4 4 7.271429 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 1.377777 $51.2500 $37.2000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 6 6 8.649206 $51.2500 $5.9300
Screening, Eval, and Assessment, Class # 02
OCTH -97165 OT EVAL LOW COMPLEXITY 24 24 27.285714 $1585.5700 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 7 7 7.000000 $406.7700 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 11 11 16.571429 $962.9600 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $58.1100 $58.1100
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 41 44 52.857143 $3071.5300 $58.1100
EI Services, Class # 03
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1 1 2.833333 $141.6700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 0.755556 $37.7800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 2.966667 $148.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 2.833333 $70.8300 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 3 3 21.285714 $1064.2900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 76 78 413.271426 $22316.6800 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 3 3 14.428571 $779.1400 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 50 53 368.576192 $29972.6000 $81.3200
OCCT -97530GT OT SESSION BY LICENSED OT 7 7 37.014285 $3010.0100 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 8 8 95.142855 $6195.7100 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 17 17 70.138095 $5703.6400 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 1 1 0.666667 $54.2200 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 62 65 419.909523 $34147.0600 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 5 6 22.352381 $1817.7100 $81.3200
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 182 245 1472.174598 $105459.6700 $71.6400
-------------------------------------------------------------------------------------------------------------------------------------
Total 295 1533.680947 $108582.4500 $70.8000
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 215