Summary Report for FSPSAs Ending During the Report Period Center: 52
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: 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 666 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 3 3 3.044445 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 3.044445 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
OCTH -97165 OT EVAL LOW COMPLEXITY 5 6 6.000000 $348.6600 $58.1100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 6 6 7.000000 $406.7700 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
SCREEN-T1023 SCREENING 7 7 7.000000 $377.8600 $53.9800
SPCH -92521 EVAL OF SPEECH FLUENCY 9 9 9.800000 $569.4800 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 2.000000 $116.2200 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $58.1100 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 7 7 30.657143 $1781.4900 $58.1100
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Subtotal (Total Children Is Unduplicated) 37 44 69.457143 $4007.2500 $57.6900
EI Services, Class # 03
CONIF -CONIF CONSULT, ITDS FACE TO FACE 126 151 358.466667 $17923.3400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 77 82 228.966670 $11448.3500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 37 42 107.133334 $5356.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 49 50 128.033333 $6401.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 2.933333 $73.3300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 197 211 940.114285 $50766.1600 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 0.066667 $3.6000 $54.0300
OCCT -97530 OT SESSION BY LICENSED OT 25 29 103.957138 $8453.7800 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.600000 $104.1900 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 20 21 79.504762 $6465.3300 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 2 2 4.319047 $351.2200 $81.3200
PHY -97110HM PT SESSION BY PT ASST 3 4 11.276191 $734.3100 $65.1200
PHY -97110HMGT PT SESSION BY PT ASST 1 1 0.142857 $9.3100 $65.1400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 22 22 90.209522 $7335.8200 $81.3200
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Subtotal (Total Children Is Unduplicated) 246 619 2056.723806 $115427.0800 $56.1200
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Total 666 2129.225394 $119434.3300 $56.0900
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Number of Children (Unduplicated) With at Least One Authorization 260