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: 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 1168 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 48 53 21.133332 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 48 53 21.133332 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
OCTH -97165TL OT EVAL LOW COMPLEXITY 1 1 0.027778 $1.6200 $58.1600
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 0.133333 $7.7500 $58.1000
OCTH -97167TL OT EVAL HIGH COMPLEXITY 5 5 0.627778 $36.4800 $58.1100
PSTH -97161TL PT EVAL LOW COMPLEXITY 1 1 0.172222 $10.0100 $58.1000
PSTH -97163TL PT EVAL HIGH COMPLEXITY 10 10 2.872222 $166.9000 $58.1100
SPCH -92521TL EVAL OF SPEECH FLUENCY 7 7 1.583333 $92.0100 $58.1100
SPCH -92522TL EVAL OF SPCH SOUND PROD 1 1 0.133333 $7.7500 $58.1000
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Subtotal (Total Children Is Unduplicated) 22 26 5.549999 $322.5000 $58.1100
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 29 71 18.252778 $912.6400 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 9 9 7.501588 $375.0800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 10 10 8.906350 $445.3200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.677778 $16.9500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 0.144444 $7.2200 $49.9800
CONSF -CONSF CONSULT, SLP, FACE TO FACE 7 7 5.106350 $255.3200 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 12.428572 $335.5700 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 176 195 1184.285704 $63951.4500 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 0.857143 $46.2800 $54.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 683 764 5102.541265 $61230.5000 $12.0000
OCCT -97530TL OT SESSION BY LICENSED OT 6 6 22.357144 $1818.0800 $81.3200
PHY -97110TL PT SESSION BY LICENSED PT 12 13 66.571429 $5413.5900 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 6 6 32.604762 $2651.4200 $81.3200
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Subtotal (Total Children Is Unduplicated) 734 1089 6463.235307 $137691.0500 $21.3000
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Total 1168 6489.918638 $138013.5500 $21.2700
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Number of Children (Unduplicated) With at Least One Authorization 774