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: 10-01-22 and 12-31-22 Date of Report: 01-23-23 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 914 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 44 45 19.255551 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 44 45 19.255551 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 2 0.366667 $20.5700 $56.1100
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 2 0.266666 $12.0800 $45.3100
OCTH -97165 OT EVAL LOW COMPLEXITY 3 3 0.433333 $22.2800 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.194444 $9.9900 $51.4000
OCTH -97167 OT EVAL HIGH COMPLEXITY 3 3 0.666667 $34.2800 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 0.138889 $7.1400 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.027778 $1.4300 $51.4500
PSTH -97161TL PT EVAL LOW COMPLEXITY 1 1 0.350000 $17.9900 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 3 3 9.344444 $480.4000 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 0.188889 $9.7100 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 7 7 17.823810 $916.3200 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 0.400000 $20.5600 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 9.000000 $403.7400 $44.8600
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Subtotal (Total Children Is Unduplicated) 21 28 39.201587 $1956.5000 $49.9100
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.000000 $50.0000 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.027778 $6.4400 $231.8000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 20 51 10.966671 $548.3600 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 2 3 1.022223 $51.1200 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 4 5 7.315079 $365.7500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 1.222223 $30.5600 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 2 2 0.455555 $22.7800 $49.9900
CONSP -CONSP CONSULT, SLP, PHONE 2 2 0.266667 $6.6700 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 3 3 25.571428 $639.2900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 2.571429 $64.2900 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 5.857143 $292.8600 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 2.285714 $114.2900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 91 95 583.428574 $29171.4200 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 27 27 167.857145 $8392.8500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 589 633 3795.873049 $37958.7100 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 4 4 13.857143 $997.1600 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 1 1 12.571429 $724.1100 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 2 2 15.000000 $1079.4000 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 1 1 9.000000 $647.6400 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 5 5 32.857143 $2364.4000 $71.9600
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Subtotal (Total Children Is Unduplicated) 633 841 4689.006393 $83528.0600 $17.8100
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Total 914 4747.463531 $85484.5600 $18.0100
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Number of Children (Unduplicated) With at Least One Authorization 683