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: 01-01-24 and 03-31-24 Date of Report: 04-04-25 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 350 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 23 30.884126 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 22 23 30.884126 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 12 12 9.883333 $479.3400 $48.5000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 1.000000 $15.1900 $15.1900
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 7 7 5.255556 $127.6100 $24.2800
AUDE -92650 AEP SCR AUDITORY POTENTIAL 1 1 1.000000 $54.9000 $54.9000
EXIT -EXIT COS Exit 3 3 4.000000 $200.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 24 24 21.138889 $877.0400 $41.4900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 7 6.311111 $31555.5000 $4999.9900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 15 20 12.142857 $607.1500 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 7 7 4.535714 $226.7900 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 3 3 2.983333 $149.1700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 38 39 50.411111 $2520.5600 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 1 1 0.055556 $2.7800 $50.0400
CONPF -CONPF CONSULT, PT, FACE TO FACE 30 31 41.242062 $2062.0900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 53 56 131.209523 $6560.4800 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 1 1 4.200000 $210.0000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 4.183333 $104.5800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 38 39 190.909527 $10309.1100 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 2.714286 $146.5700 $54.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 59 74 462.946828 $5555.3600 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 6 6 23.742858 $1930.7800 $81.3200
OCCT -97530TL OT SESSION BY LICENSED OT 2 2 13.142858 $1068.7700 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 1 1 2.000000 $162.6400 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 1 1 3.200000 $260.2200 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 7 7 19.677777 $1600.1900 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 3 3 19.000000 $1545.0800 $81.3200
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Subtotal (Total Children Is Unduplicated) 204 303 994.608734 $66577.8100 $66.9400
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Total 350 1046.631749 $67454.8500 $64.4500
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Number of Children (Unduplicated) With at Least One Authorization 230