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: 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 703 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 10 10 8.144444 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 10 10 8.144444 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
OCTH -97165 OT EVAL LOW COMPLEXITY 10 10 10.000000 $581.1000 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 3 3 3.000000 $174.3300 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
SCREEN-T1023 SCREENING 12 12 12.000000 $647.7600 $53.9800
SPCH -92521 EVAL OF SPEECH FLUENCY 3 4 4.000000 $232.4400 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 3.857143 $224.1400 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 9 9 37.742859 $2193.2500 $58.1100
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Subtotal (Total Children Is Unduplicated) 41 45 73.600002 $4227.3400 $57.4400
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 2 4.133333 $206.6700 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 130 150 405.383338 $20269.1900 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 1 1 1.000000 $50.0000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 72 78 218.200002 $10910.0100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.733333 $68.3300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 32 37 108.966667 $5448.3400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 59 63 179.266670 $8963.3500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 2.166667 $54.1700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 211 219 1078.380962 $58232.5400 $54.0000
INTR -T1013 INTERPRETER 1 1 13.000000 $650.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 27 30 89.880953 $7309.1200 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 3 3 21.714286 $1414.0400 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 22 26 97.114287 $7897.3400 $81.3200
PHY -97110HM PT SESSION BY PT ASST 5 5 30.847619 $2008.8000 $65.1200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 30 30 110.547620 $8989.7200 $81.3200
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Subtotal (Total Children Is Unduplicated) 264 648 2363.335737 $132471.6100 $56.0500
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Total 703 2445.080183 $136698.9500 $55.9100
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Number of Children (Unduplicated) With at Least One Authorization 290