Summary Report for FSPSAs Initiated During the Report Period Center: 03
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: 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 627 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 28 28 15.011111 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 28 28 15.011111 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 5 7 4.400000 $213.4000 $48.5000
OCTH -97165 OT EVAL LOW COMPLEXITY 6 6 2.294444 $117.9600 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 14 15 9.455556 $486.1100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 13 18 5.111110 $262.7600 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 34 44 21.159134 $1087.8000 $51.4100
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Subtotal (Total Children Is Unduplicated) 66 90 42.420244 $2168.0200 $51.1100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 7 5.215677 $26078.0000 $4999.9300
CONIF -CONIF CONSULT, ITDS FACE TO FACE 5 5 8.133334 $406.6700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 33 36 42.599999 $2130.0000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 22 25 24.855555 $1242.7800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 40 47 60.583332 $3029.1600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 207 291 1267.376192 $63368.8200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 6 6 26.304762 $1892.8900 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 30 39 172.652378 $12424.0500 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 35 53 167.253967 $12035.5800 $71.9600
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Subtotal (Total Children Is Unduplicated) 280 509 1774.975196 $122607.9400 $69.0800
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Total 627 1832.406551 $124775.9600 $68.0900
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Number of Children (Unduplicated) With at Least One Authorization 307