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
Eligibility Filter: Program Patients
With the filters selected there were 694 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 22 22 17.611112 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 22 22 17.611112 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
OCTH -97167TL OT EVAL HIGH COMPLEXITY 4 5 1.638889 $84.2600 $51.4100
PSTH -97161TL PT EVAL LOW COMPLEXITY 1 1 0.133333 $6.8500 $51.4000
PSTH -97163TL PT EVAL HIGH COMPLEXITY 4 4 1.122223 $57.7000 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 3 3 1.083333 $55.6900 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.466667 $23.9900 $51.4100
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Subtotal (Total Children Is Unduplicated) 10 14 4.444445 $228.4900 $51.4100
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 2.000000 $463.2400 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 25 40 9.566668 $478.3400 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 7 7 6.755555 $337.7800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 6 6 4.885714 $244.2900 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 0.844444 $42.2200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 3 3 2.833333 $141.6700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 114 118 1082.285720 $54114.2500 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 7.428571 $371.4300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 449 467 4071.307161 $48855.6700 $12.0000
OCCT -97530TL OT SESSION BY LICENSED OT 4 5 33.000001 $2374.6800 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 5 5 34.571428 $2487.7700 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 3 3 18.000000 $1295.2800 $71.9600
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Subtotal (Total Children Is Unduplicated) 481 658 5273.478595 $111206.6000 $21.0900
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Total 694 5295.534152 $111435.0900 $21.0400
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Number of Children (Unduplicated) With at Least One Authorization 503