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: 04-01-23 and 06-30-23 Date of Report: 07-25-23 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2032 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 51 52 36.123014 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 51 52 36.123014 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 6 6 6.000000 $336.6000 $56.1000
OCTH -97165 OT EVAL LOW COMPLEXITY 3 3 0.644444 $33.1300 $51.4100
OCTH -97165TL OT EVAL LOW COMPLEXITY 9 9 2.205556 $113.3900 $51.4100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 2 2 0.511111 $26.2800 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 7 8 1.416667 $72.8300 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 42 48 11.473015 $589.8300 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 0.383334 $19.7100 $51.4200
PSTH -97161TL PT EVAL LOW COMPLEXITY 2 2 0.661111 $33.9900 $51.4100
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 2 2 0.505556 $25.9900 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 5 6 1.161112 $59.7000 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 34 37 26.082537 $1340.8900 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 0.505555 $25.9900 $51.4000
SPCH -92521TL EVAL OF SPEECH FLUENCY 37 40 12.502378 $642.7300 $51.4100
SPCH -92521TLGT EVAL OF SPEECH FLUENCY 2 2 0.316667 $16.2800 $51.4200
SPCH -92522TL EVAL OF SPCH SOUND PROD 5 7 1.061110 $54.5500 $51.4000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 6 6 1.083332 $55.6900 $51.4000
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 2 3 0.483333 $24.8500 $51.4100
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 0.600000 $30.8500 $51.4100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 2 2 22.428572 $1153.0500 $51.4100
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Subtotal (Total Children Is Unduplicated) 114 190 90.025390 $4656.3100 $51.7200
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $231.6200 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 27 75 17.795231 $889.7300 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 4 4 1.922222 $96.1100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 3 3.111110 $77.7800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 9 9 2.177777 $108.8900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 2 2.366666 $59.1700 $25.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.744444 $18.6100 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 6 6 2.879365 $143.9700 $50.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 2 2 1.857143 $46.4300 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 110 144 850.571429 $21264.2800 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 8.714286 $435.7200 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 137 140 786.857145 $39342.8400 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 450 492 3235.201594 $161760.0700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 559 611 3907.628586 $46891.5400 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 5 6 19.000001 $1367.2400 $71.9600
OCCT -97530TL OT SESSION BY LICENSED OT 80 93 543.142857 $39084.5000 $71.9600
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 2.857143 $205.6000 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 6 7 33.857145 $2436.3500 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 65 75 466.642860 $33579.5500 $71.9600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 1.000000 $459.2200 $459.2200
SENS -V5264 EARMOLD 1 1 1.000000 $18.1300 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 4 4 22.714286 $1634.5100 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 89 109 536.214288 $38585.9200 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 2 2 7.714286 $555.1100 $71.9600
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Subtotal (Total Children Is Unduplicated) 740 1790 10456.969864 $389292.8600 $37.2300
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Total 2032 10583.118268 $393949.1700 $37.2200
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Number of Children (Unduplicated) With at Least One Authorization 783