Summary Report for FSPSAs Initiated During the Report Period Center: 51
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: 10-01-24 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 252 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
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 4.866666 $181.0400 $37.2000
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Subtotal (Total Children Is Unduplicated) 2 2 4.866666 $181.0400 $37.2000
Screening, Eval, and Assessment, Class # 02
OCTH -97165 OT EVAL LOW COMPLEXITY 11 11 17.000000 $987.8700 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 3 3 3.000000 $174.3300 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 3 3 14.857143 $863.3500 $58.1100
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Subtotal (Total Children Is Unduplicated) 17 18 35.857143 $2083.6600 $58.1100
EI Services, Class # 03
CONOF -CONOF CONSULT, OT, FACE TO FACE 1 1 1.833333 $91.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.544444 $13.6100 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 1.833333 $91.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.544444 $13.6100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 80 82 495.214288 $26741.5700 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 3 3 21.857143 $1180.2800 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 49 50 282.485714 $22971.7500 $81.3200
OCCT -97530GOGT OT SESSION BY LICENSED OT 1 1 6.571429 $534.3900 $81.3200
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 -77.428571 $-6296.4900 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 9 9 68.428571 $4456.0600 $65.1200
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 9.857143 $641.8900 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 14 14 78.623810 $6393.7000 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 64 66 418.642857 $34044.0200 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 10.857143 $882.9000 $81.3200
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Subtotal (Total Children Is Unduplicated) 182 232 1319.865081 $91760.6200 $69.5200
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Total 252 1360.588890 $94025.3100 $69.1100
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Number of Children (Unduplicated) With at Least One Authorization 190