Summary Report for FSPSAs Initiated During the Report Period Center: 52
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 691 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 0.833333 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 0.833333 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
OCTH -97165 OT EVAL LOW COMPLEXITY 10 10 9.233333 $536.5500 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 6 7 8.000000 $464.8800 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
SCREEN-T1023 SCREENING 9 9 9.000000 $485.8200 $53.9800
SPCH -92521 EVAL OF SPEECH FLUENCY 7 7 7.800000 $453.2600 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 7 8 31.657145 $1839.6000 $58.1100
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Subtotal (Total Children Is Unduplicated) 37 45 69.690478 $4012.5500 $57.5800
EI Services, Class # 03
CONIF -CONIF CONSULT, ITDS FACE TO FACE 134 151 341.466666 $17073.3300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 73 78 206.199998 $10309.9900 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 44 49 169.999998 $8499.9900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 55 55 147.033333 $7351.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 8 8 26.866668 $671.6700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 196 207 841.477382 $45439.7800 $54.0000
INTR -T1013 INTERPRETER 2 2 10.809524 $540.4800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 29 33 117.533335 $9557.8200 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 4 4 20.838096 $1356.9800 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 25 26 107.090479 $8708.6000 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 1 1 2.966667 $241.2500 $81.3200
PHY -97110HM PT SESSION BY PT ASST 4 5 29.619048 $1928.7900 $65.1200
PHY -97110HMGT PT SESSION BY PT ASST 1 1 12.714286 $827.9600 $65.1200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 22 23 110.519051 $8987.4100 $81.3200
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Subtotal (Total Children Is Unduplicated) 254 643 2145.134531 $121495.7100 $56.6400
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Total 691 2215.658342 $125508.2600 $56.6500
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Number of Children (Unduplicated) With at Least One Authorization 267