Summary Report for FSPSAs Ending During the Report Period Center: 51
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: 10-01-21 and 12-31-21 Date of Report: 02-04-22 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 22 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 7 7 16.658731 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 7 7 16.658731 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 2 3 3.000000 $150.0000 $50.0000
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
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Subtotal (Total Children Is Unduplicated) 4 5 5.000000 $252.1000 $50.4200
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 0.750000 $37.5000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 0.066667 $1.6700 $25.0100
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 0.633333 $31.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 5.857143 $146.4300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1 1 11.714286 $585.7200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 3 3 22.285714 $1592.1000 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 2 16.142857 $1153.2500 $71.4400
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Subtotal (Total Children Is Unduplicated) 8 10 57.450000 $3548.3200 $61.7600
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Total 22 79.108731 $3800.4200 $48.0400
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Number of Children (Unduplicated) With at Least One Authorization 17