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: 01-01-25 and 03-31-25 Date of Report: 04-06-25 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 514 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 36 36 18.233329 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 36 36 18.233329 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 4 4 2.350000 $113.9800 $48.5000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 4 4 3.188889 $101.4400 $31.8100
OCTH -97167 OT EVAL HIGH COMPLEXITY 17 20 15.898412 $923.8600 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 11 11 4.811111 $279.5700 $58.1100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 0.472222 $27.4400 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 16 18 26.358730 $1531.7000 $58.1100
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 45 58 53.079364 $2977.9900 $56.1000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 5 5.000000 $25000.0000 $5000.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 6 6 19.660318 $983.0200 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 31 35 38.655558 $1932.7900 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 15 19 15.455556 $772.7800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 28 32 37.174604 $1858.7400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 186 256 980.404777 $52941.8900 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 1.000000 $54.0000 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 18 26 95.485715 $7764.9100 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 13 16 82.733334 $6727.8600 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 16 24 95.723810 $7784.2500 $81.3200
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 237 420 1371.293672 $105820.2300 $77.1700
-------------------------------------------------------------------------------------------------------------------------------------
Total 514 1442.606365 $108798.2100 $75.4200
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 271