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: 04-01-25 and 06-30-25 Date of Report: 07-19-25 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 676 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 0.666667 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 0.666667 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 2.000000 $90.6400 $45.3200
OCTH -97165 OT EVAL LOW COMPLEXITY 9 9 9.000000 $522.9900 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 3 3 3.000000 $174.3300 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 4 4 4.000000 $232.4400 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 3.000000 $174.3300 $58.1100
SCREEN-T1023 SCREENING 17 17 17.000000 $917.6600 $53.9800
SPCH -92521 EVAL OF SPEECH FLUENCY 7 7 7.000000 $406.7700 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 7 7 10.833333 $629.5200 $58.1100
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Subtotal (Total Children Is Unduplicated) 45 51 55.833333 $3148.6800 $56.3900
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 1.000000 $50.0000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 130 160 364.949997 $18247.4900 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 1 1 1.000000 $50.0000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.400000 $35.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 51 56 151.266663 $7563.3200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.300000 $7.5000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 31 40 117.799998 $5889.9900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 60 64 153.866665 $7693.3300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 17.866666 $446.6700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 191 207 850.028567 $45901.5500 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 25 26 96.780954 $7870.2500 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 2 2 11.428571 $744.2300 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 23 25 77.414285 $6295.3500 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 1 1 2.533333 $206.0100 $81.3200
PHY -97110HM PT SESSION BY PT ASST 5 5 12.238096 $796.9500 $65.1200
PHY -97110HMGT PT SESSION BY PT ASST 1 1 10.857143 $707.0100 $65.1200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 27 27 95.157144 $7738.1800 $81.3200
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Subtotal (Total Children Is Unduplicated) 238 622 1965.888082 $110242.8000 $56.0800
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Total 676 2022.388082 $113391.4800 $56.0700
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Number of Children (Unduplicated) With at Least One Authorization 255