Summary Report for FSPSAs Ending During the Report Period Center: 57
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: 10-01-21 and 12-31-21 Date of Report: 02-04-22 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2367 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 4 4 7.098412 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 16 16 7.522220 $278.3100 $37.0000
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Subtotal (Total Children Is Unduplicated) 20 20 14.620632 $278.3100 $19.0400
Screening, Eval, and Assessment, Class # 02
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 1.000000 $9.7900 $9.7900
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 2 2 2.000000 $102.1400 $51.0700
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 3.344444 $150.5000 $45.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 3 4 3.455556 $176.4100 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 39 39 22.926190 $1170.3800 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 3 2.361111 $120.5300 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 19 21 9.105554 $464.8300 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 40 41 20.242857 $1033.4000 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.244444 $12.4800 $51.0400
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 19 21 15.061112 $670.9800 $44.5500
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Subtotal (Total Children Is Unduplicated) 91 138 80.741268 $3962.4900 $49.0800
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 2 0.511112 $25.5600 $50.0100
CONOF -CONOF CONSULT, OT, FACE TO FACE 331 338 394.999197 $19749.9300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 40 40 57.984128 $2899.2200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 403 408 397.707927 $19885.3500 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 45 47 259.571429 $6489.2900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 596 608 4098.907952 $204945.3900 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 3 3 10.714285 $535.7200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 596 619 4093.756365 $40937.5600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 44 45 178.571432 $12757.1400 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 5 5 19.785714 $1131.7400 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 20 21 81.353176 $5811.8600 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 1.500000 $107.1600 $71.4400
PHY -97110HM PT SESSION BY PT ASST 8 9 44.498017 $2543.4900 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 59 60 265.642860 $18977.5100 $71.4400
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 1 1 5.285714 $302.3400 $57.2000
SPL -92508HA GROUP SPL SESSION PER CHILD 1 1 1.785714 $24.7900 $13.8800
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Subtotal (Total Children Is Unduplicated) 651 2209 9913.575022 $337354.0400 $34.0300
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Total 2367 10008.936922 $341594.8400 $34.1300
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Number of Children (Unduplicated) With at Least One Authorization 681