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 445 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 -97167TL OT EVAL HIGH COMPLEXITY 1 1 0.338889 $17.4200 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 0.338889 $17.4200 $51.4100
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Subtotal (Total Children Is Unduplicated) 2 2 0.677778 $34.8500 $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
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 14 15 151.428572 $7571.4300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 347 360 3114.450014 $37373.3900 $12.0000
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 8.714286 $627.0800 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 1 1 8.714286 $627.0800 $71.9600
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Subtotal (Total Children Is Unduplicated) 373 425 3304.787319 $47272.9900 $14.3000
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Total 445 3320.887320 $47307.8400 $14.2500
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Number of Children (Unduplicated) With at Least One Authorization 390