Summary Report for FSPSAs Ending During the Report Period Center: 04
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: 10-01-23 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 628 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 43 44 25.971425 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 43 44 25.971425 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
OCTH -97167TL OT EVAL HIGH COMPLEXITY 2 2 0.833333 $42.8400 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 3 3 1.061111 $54.5500 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 2 2 0.594444 $30.5600 $51.4100
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Subtotal (Total Children Is Unduplicated) 4 7 2.488888 $127.9500 $51.4100
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 22 57 10.100000 $505.0000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 3 3 1.977777 $98.8900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 4 4 4.336508 $216.8300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 1.688888 $84.4400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 5 5 47.857143 $2392.8600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 8 8 43.714286 $2185.7200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 468 494 3381.077791 $40572.9300 $12.0000
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 11.285714 $812.1200 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 2 2 15.714285 $1130.8000 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 3.714286 $267.2800 $71.9600
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Subtotal (Total Children Is Unduplicated) 494 577 3521.466678 $48266.8700 $13.7100
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Total 628 3549.926991 $48394.8200 $13.6300
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Number of Children (Unduplicated) With at Least One Authorization 534