Summary Report for FSPSAs Initiated During the Report Period Center: 57
This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start 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 starting 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 1279 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 7 7 4.322220 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.244444 $9.0400 $36.9900
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 7 8 4.566664 $9.0400 $1.9800
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.0000 $45.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 3 3 2.055556 $104.9400 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 17 18 8.444444 $431.0900 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 2 2.000000 $102.1000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 7 7 2.599999 $132.7200 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 14 14 4.533333 $231.4300 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 5 6 7.272222 $323.9800 $44.5500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 28 51 27.905554 $1371.2500 $49.1400
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 2 4 1.411112 $70.5600 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1 1 0.677778 $33.8900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 289 298 347.896826 $17394.8400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.522222 $13.0600 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 34 34 49.957145 $2497.8700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 344 352 343.675400 $17183.7800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.500000 $12.5000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 3.398413 $84.9600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 174 185 1250.542853 $62527.1800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 314 325 2732.420641 $27324.2100 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 3 3 6.714286 $479.6700 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 2 2 16.428572 $939.7200 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 4 5 28.138888 $2010.2400 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 12.285715 $702.2500 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 4 18.857142 $1347.1500 $71.4400
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 486 1220 4814.426993 $132851.8600 $27.5900
-------------------------------------------------------------------------------------------------------------------------------------
Total 1279 4846.899211 $134232.1500 $27.6900
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 502