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: 10-01-24 and 12-31-24 Date of Report: 03-31-25 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 53 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
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 0.677778 $25.2100 $37.2000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 1 1 1.100000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 1.777778 $25.2100 $14.1800
Screening, Eval, and Assessment, Class # 02
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 1.000000 $58.1100 $58.1100
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Subtotal (Total Children Is Unduplicated) 4 4 4.000000 $232.4400 $58.1100
EI Services, Class # 03
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 13.571428 $678.5700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.166667 $54.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 1.833333 $91.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 1.000000 $50.0000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 2.166667 $54.1700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 13 13 90.357145 $4879.2800 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 11 12 54.052382 $4395.5500 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 2 2 13.285714 $865.1700 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 2 2 5.785714 $470.5000 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 1 1 3.428571 $278.8100 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 8 9 41.576190 $3380.9700 $81.3200
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Subtotal (Total Children Is Unduplicated) 33 47 229.223811 $15198.8500 $66.3100
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Total 53 235.001589 $15456.5100 $65.7700
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Number of Children (Unduplicated) With at Least One Authorization 38