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: 04-01-23 and 06-30-23 Date of Report: 07-25-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 240 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 41 41 36.033332 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 41 41 36.033332 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 4 5 4.372222 $212.0500 $48.5000
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 1.500000 $77.1200 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 3 0.722222 $37.1300 $51.4100
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Subtotal (Total Children Is Unduplicated) 7 11 7.594444 $377.7100 $49.7300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 8 8 11.027779 $551.4000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 53 66 58.455555 $2922.7800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 32 34 32.633332 $1631.6600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 50 54 51.155558 $2557.7900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 17 18 59.028571 $2951.4300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 12.857143 $925.2000 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 3 3 3.714286 $267.2800 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 3 15.523809 $1117.0900 $71.9600
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Subtotal (Total Children Is Unduplicated) 142 188 245.396033 $17924.6100 $73.0400
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Total 240 289.023809 $18302.3100 $63.3200
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Number of Children (Unduplicated) With at Least One Authorization 184