Summary Report for FSPSAs Ending During the Report Period Center: 03
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: 10-01-22 and 12-31-22 Date of Report: 01-23-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 828 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 30 31 17.566667 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 30 31 17.566667 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 18 20 13.633333 $661.2200 $48.5000
OCTH -97165 OT EVAL LOW COMPLEXITY 20 20 13.366667 $687.1800 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 2 2 0.183333 $9.4200 $51.4000
PSTH -97161 PT EVAL LOW COMPLEXITY 22 24 13.619843 $700.2000 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 14 19 6.111112 $314.1800 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 0.133333 $6.8500 $51.4000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 45 51 22.361647 $1149.6300 $51.4100
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Subtotal (Total Children Is Unduplicated) 100 137 69.409268 $3528.6800 $50.8400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 16 17 13.261112 $66306.0000 $5000.0300
CONIF -CONIF CONSULT, ITDS FACE TO FACE 16 16 15.377778 $768.8900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 51 56 61.622219 $3081.1000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 34 37 37.144444 $1857.2200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 53 57 47.955558 $2397.7900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 308 337 1166.707941 $58335.3700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 22 23 128.700002 $9261.2500 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 45 54 209.038098 $15042.3700 $71.9600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.150685 $34.6000 $229.6300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 51 62 199.447625 $14352.2400 $71.9600
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Subtotal (Total Children Is Unduplicated) 423 660 1879.405462 $171436.8300 $91.2200
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Total 828 1966.381397 $174965.5100 $88.9800
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Number of Children (Unduplicated) With at Least One Authorization 454