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: 10-01-23 and 12-31-23 Date of Report: 01-14-24 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1906 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 53 54 28.326981 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 53 54 28.326981 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 5 5 4.272222 $239.6700 $56.1000
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.244444 $12.5600 $51.4000
OCTH -97165TL OT EVAL LOW COMPLEXITY 2 2 0.416667 $21.4200 $51.4100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 2 2 0.633333 $32.5600 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 2 3 0.483334 $24.8500 $51.4200
OCTH -97167TL OT EVAL HIGH COMPLEXITY 50 52 16.583331 $852.5400 $51.4100
PSTF -97164TL PT RE-EVAL EST PLAN CARE 1 1 0.305556 $15.7100 $51.4200
PSTH -97161TL PT EVAL LOW COMPLEXITY 1 1 0.283333 $14.5600 $51.4000
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 0.116667 $6.0000 $51.4200
PSTH -97163TL PT EVAL HIGH COMPLEXITY 46 49 12.005555 $617.2000 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 41 45 12.688884 $652.3100 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 2 2 0.311111 $15.9900 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.044444 $53.6900 $51.4100
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 0.994444 $51.1200 $51.4100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 2 2 38.285714 $1968.2700 $51.4100
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Subtotal (Total Children Is Unduplicated) 109 170 88.669039 $4578.4700 $51.6400
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 3.000000 $694.8600 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 24 62 10.350001 $517.5100 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 4 4 2.944444 $147.2200 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 6 6 5.314286 $265.7200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 1.688888 $84.4400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 0.011111 $0.5600 $49.9500
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 1.000000 $25.0000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 86 109 518.999997 $12975.0100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 335 351 2607.714288 $130385.7200 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 273 274 1760.000012 $88000.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 589 622 4312.469062 $51749.6300 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 3 3 10.785714 $776.1400 $71.9600
OCCT -97530TL OT SESSION BY LICENSED OT 80 91 465.357146 $33487.1000 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 2 2 6.071429 $436.9000 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 58 63 325.142858 $23397.2700 $71.9600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 1.000000 $114.8100 $114.8100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 2.000000 $918.4400 $459.2200
SENS -V5264 EARMOLD 3 3 3.000000 $54.3900 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 4.642857 $334.1000 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 68 81 363.999998 $26193.4800 $71.9600
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Subtotal (Total Children Is Unduplicated) 728 1682 10405.492091 $370558.2700 $35.6100
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Total 1906 10522.488111 $375136.7400 $35.6500
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Number of Children (Unduplicated) With at Least One Authorization 778