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: 10-01-23 and 12-31-23 Date of Report: 01-14-24 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 612 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 42 42 21.833332 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 42 42 21.833332 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 4 4 4.000000 $194.0000 $48.5000
OCTH -97165 OT EVAL LOW COMPLEXITY 12 12 3.644445 $187.3600 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 7 7 3.772222 $193.9300 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 21 22 9.444445 $485.5400 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 43 44 30.550000 $1570.5800 $51.4100
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Subtotal (Total Children Is Unduplicated) 79 89 51.411112 $2631.4100 $51.1800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 6 4.961111 $24805.5000 $4999.9900
CONIF -CONIF CONSULT, ITDS FACE TO FACE 6 7 8.577778 $428.8900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 37 48 70.088890 $3504.4500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 26 29 33.533333 $1676.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 36 41 49.707936 $2485.4000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 171 237 1029.714297 $51485.7000 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 7.571429 $378.5700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 15 23 80.619046 $5801.3400 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 32 38 142.773014 $10273.9600 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 43 51 245.804765 $17688.1100 $71.9600
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Subtotal (Total Children Is Unduplicated) 274 481 1673.351599 $118528.5800 $70.8300
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Total 612 1746.596043 $121159.9900 $69.3700
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Number of Children (Unduplicated) With at Least One Authorization 317