Summary Report for FSPSAs Initiated During the Report Period Center: 53
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: 07-01-23 and 09-30-23 Date of Report: 10-10-23 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 380 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 14 14 17.472224 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 14 14 17.472224 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 6 6 5.344444 $259.2000 $48.5000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 1.000000 $15.8400 $15.8400
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 0.411111 $9.0700 $22.0700
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 2.785714 $348.2100 $125.0000
EXIT -EXIT COS Exit 1 1 1.000000 $50.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 11 11 10.541269 $682.3300 $64.7300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.000000 $10000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 11 12 9.169047 $458.4500 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 6 6 5.000000 $250.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 4 4 4.144445 $207.2300 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 1 1 1.377778 $68.8900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 43 46 66.063972 $3303.2100 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 3 3 2.377778 $118.8900 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 23 25 38.050003 $1902.5200 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 1 1 0.933333 $46.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 32 32 44.703173 $2235.1500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 1.333334 $33.3400 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 4 22.923810 $1146.2000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 23 23 122.776193 $6138.8100 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 8.285714 $414.2900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 152 176 887.710321 $10652.5200 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 7 8 36.409524 $2620.0300 $71.9600
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 1.600000 $115.1400 $71.9600
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 3.133333 $225.4700 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 1 1 4.857143 $349.5200 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 4 4 24.500000 $1763.0200 $71.9600
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Subtotal (Total Children Is Unduplicated) 245 355 1288.348901 $42074.3100 $32.6600
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Total 380 1316.362394 $42756.6400 $32.4800
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Number of Children (Unduplicated) With at Least One Authorization 262