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: 10-01-22 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 11 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 1 1 0.285714 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 0.285714 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 2 2.000000 $102.8200 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
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Subtotal (Total Children Is Unduplicated) 2 3 3.000000 $154.2300 $51.4100
EI Services, Class # 03
CONOF -CONOF CONSULT, OT, FACE TO FACE 1 1 0.866667 $43.3400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 1.666667 $83.3400 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 0.433333 $21.6700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 8.857143 $637.3600 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 3 18.428572 $1326.1100 $71.9600
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Subtotal (Total Children Is Unduplicated) 6 7 30.252382 $2111.8100 $69.8100
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Total 11 33.538096 $2266.0400 $67.5700
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Number of Children (Unduplicated) With at Least One Authorization 9