Summary Report for FSPSAs Initiated During the Report Period Center: 04
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 1016 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 18 18 15.422223 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 18 18 15.422223 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 0.144444 $7.4200 $51.3900
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 0.361111 $18.5600 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 25 25 16.427775 $844.5400 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 15 15 5.194443 $267.0400 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 17 18 23.461107 $1206.1100 $51.4100
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Subtotal (Total Children Is Unduplicated) 39 60 45.588880 $2343.6800 $51.4100
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 23 37 9.116669 $455.8500 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 5 5 5.288889 $264.4500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 5 5 4.874603 $243.7300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 2.200000 $110.0000 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 51 59 375.714292 $9392.8500 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 349 360 3132.000013 $156599.9500 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 2 2 18.285714 $914.2900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 347 360 3114.450014 $37373.3900 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 3.071429 $221.0200 $71.9600
OCCT -97530TL OT SESSION BY LICENSED OT 50 51 319.626197 $23000.2600 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 2 2 9.785715 $704.1800 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 25 25 198.214289 $14263.4700 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 28 30 158.500003 $11405.6400 $71.9600
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Subtotal (Total Children Is Unduplicated) 411 938 7351.127827 $254949.0500 $34.6800
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Total 1016 7412.138930 $257292.7300 $34.7100
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Number of Children (Unduplicated) With at Least One Authorization 428