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 948 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 49 50 26.993648 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 49 50 26.993648 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.272222 $15.2700 $56.1000
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.244444 $12.5600 $51.4000
OCTH -97167TL OT EVAL HIGH COMPLEXITY 9 9 4.238888 $217.9200 $51.4100
PSTF -97164TL PT RE-EVAL EST PLAN CARE 1 1 0.305556 $15.7100 $51.4200
PSTH -97163TL PT EVAL HIGH COMPLEXITY 14 14 3.861111 $198.5000 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 9 9 2.483333 $127.6700 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.044444 $53.6900 $51.4100
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Subtotal (Total Children Is Unduplicated) 25 37 12.449998 $641.3200 $51.5100
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 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 -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 1.428572 $35.7200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 71 76 607.571427 $30378.5800 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 62 62 410.428575 $20521.4200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 589 622 4312.469062 $51749.6300 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 6.285714 $452.3200 $71.9600
OCCT -97530TL OT SESSION BY LICENSED OT 6 6 46.714286 $3361.5500 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 11 11 63.428572 $4564.3300 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 5 5 24.857144 $1788.7200 $71.9600
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Subtotal (Total Children Is Unduplicated) 631 861 5494.492082 $114099.3300 $20.7700
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Total 948 5533.935728 $114740.6500 $20.7300
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Number of Children (Unduplicated) With at Least One Authorization 681