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: 01-01-22 and 03-31-22 Date of Report: 04-16-22 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2030 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 42 42 26.093653 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 42 42 26.093653 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 2 0.294445 $14.2800 $48.5100
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $55.7100 $55.7100
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.083333 $3.7500 $44.9800
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 0.355555 $18.1500 $51.0400
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 0.477778 $24.3900 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 5 5 2.303968 $117.6200 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 63 65 47.244447 $2411.8500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 0.544445 $27.8000 $51.0600
PSTH -97163 PT EVAL HIGH COMPLEXITY 46 49 12.972224 $662.2400 $51.0500
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 0.366667 $18.7200 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 0.033333 $1.7000 $51.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 27 32 6.450001 $329.2800 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.366667 $18.7200 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 0.105556 $5.3900 $51.0700
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 40 41 29.173016 $1299.6600 $44.5500
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Subtotal (Total Children Is Unduplicated) 134 205 101.771435 $5009.2500 $49.2200
EI Services, Class # 03
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 1.000000 $50.0000 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.000000 $50.0000 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.000000 $68.8600 $68.8600
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 1.022222 $235.1100 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 32 99 47.814292 $2390.7400 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 2 2 1.100000 $55.0000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 1.311111 $65.5600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.261111 $6.5300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 0.211111 $10.5600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.488889 $12.2200 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 0.857143 $21.4300 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 93 109 635.714294 $15892.8400 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 11.428571 $571.4300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 592 642 4053.133327 $202656.6100 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 4 4 11.857142 $592.8600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 574 627 3942.457142 $39424.5600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 55 58 306.642858 $21906.5300 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 50 54 312.428574 $17870.8800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 38 45 240.056351 $17149.6200 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 4.785714 $341.8900 $71.4400
PHY -97110HM PT SESSION BY PT ASST 33 35 206.928575 $11828.0000 $57.1600
SENS -V5264 EARMOLD 1 1 0.033333 $0.6000 $17.9800
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 67 79 379.911115 $27140.8300 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 2.571429 $147.0800 $57.2000
SPL -92508HA GROUP SPL SESSION PER CHILD 13 13 65.499999 $909.1400 $13.8800
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Subtotal (Total Children Is Unduplicated) 744 1783 10229.514303 $359398.8600 $35.1300
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Total 2030 10357.379391 $364408.1100 $35.1800
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Number of Children (Unduplicated) With at Least One Authorization 788