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: 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 1013 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 24 24 13.177779 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 24 24 13.177779 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
OCTH -97167TL OT EVAL HIGH COMPLEXITY 31 31 9.766666 $567.5400 $58.1100
PSTH -97161TL PT EVAL LOW COMPLEXITY 1 1 0.450000 $26.1500 $58.1100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 21 21 5.238888 $304.4300 $58.1100
SPCH -92521TL EVAL OF SPEECH FLUENCY 18 18 5.849999 $339.9400 $58.1100
SPCH -92522TL EVAL OF SPCH SOUND PROD 1 1 0.077778 $4.5200 $58.1300
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 0.544444 $31.6400 $58.1100
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.255556 $14.8500 $58.1200
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 1 3.285714 $190.9300 $58.1100
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Subtotal (Total Children Is Unduplicated) 46 76 25.469045 $1479.9900 $58.1100
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 18 41 11.838893 $591.9700 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 2 2 0.811111 $40.5600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 2 2 1.439682 $71.9900 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 0.300000 $15.0000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 3 3 1.122222 $56.1100 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 57 68 483.428581 $13052.5700 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 320 331 2542.190519 $137278.2500 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 11.571429 $624.8600 $54.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 319 334 2562.310362 $30747.7200 $12.0000
OCCT -97530TL OT SESSION BY LICENSED OT 47 47 288.357143 $23449.1800 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 2 2 13.214286 $1074.5900 $81.3200
PHY -97110TL PT SESSION BY LICENSED PT 34 34 212.500002 $17280.4700 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 47 47 275.071426 $22368.8000 $81.3200
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Subtotal (Total Children Is Unduplicated) 392 913 6404.155656 $246652.0400 $38.5100
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Total 1013 6442.802480 $248132.0300 $38.5100
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Number of Children (Unduplicated) With at Least One Authorization 412