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: 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 255 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 19 19 12.644445 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 19 19 12.644445 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 3 3 5.226985 $253.5100 $48.5000
OCTH -97165 OT EVAL LOW COMPLEXITY 4 4 2.177778 $111.9600 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.005556 $0.2900 $51.8200
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.4100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 0.133334 $6.8600 $51.4400
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Subtotal (Total Children Is Unduplicated) 9 12 9.543653 $475.4400 $49.8200
EI Services, Class # 03
CONIF -CONIF CONSULT, ITDS FACE TO FACE 17 18 17.755556 $887.7800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 73 86 96.700000 $4835.0000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 24 27 34.603173 $1730.1500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 51 58 72.633331 $3631.6600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 22 27 90.028571 $4501.4300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 0.142857 $10.2800 $71.9800
PHY -97110 PT SESSION BY LICENSED PT 4 4 18.995238 $1366.9000 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 3 2.142857 $154.2000 $71.9600
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Subtotal (Total Children Is Unduplicated) 162 224 333.001583 $17117.4000 $51.4000
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Total 255 355.189681 $17592.8300 $49.5300
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Number of Children (Unduplicated) With at Least One Authorization 184