Summary Report for FSPSAs Initiated During the Report Period Center: 04
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: 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 1703 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 47.846035 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 42 42 47.846035 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 3 3 1.144444 $55.5000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $55.7100 $55.7100
OCTH -97165 OT EVAL LOW COMPLEXITY 7 7 0.933333 $47.6500 $51.0500
OCTH -97165GT OT EVAL LOW COMPLEXITY 2 2 0.311111 $15.8800 $51.0500
OCTH -97165TL OT EVAL LOW COMPLEXITY 1 1 0.161111 $8.2200 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 43 45 45.503967 $2322.9800 $51.0500
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 0.166667 $8.5100 $51.0600
PSTH -97161 PT EVAL LOW COMPLEXITY 3 3 0.622221 $31.7600 $51.0400
PSTH -97161GT PT EVAL LOW COMPLEXITY 1 1 0.322222 $16.4500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.305556 $15.6000 $51.0600
PSTH -97163 PT EVAL HIGH COMPLEXITY 32 32 10.011112 $511.0700 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 8 8 1.516666 $77.4200 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 15 17 4.794444 $244.7500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 25 26 10.659525 $474.8900 $44.5500
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 4.142857 $217.7900 $52.5700
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Subtotal (Total Children Is Unduplicated) 109 149 81.595236 $4104.1900 $50.3000
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.000000 $50.0000 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 11.285714 $777.1300 $68.8600
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 2.000000 $460.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 14 35 8.605558 $430.2900 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 5 6 2.777777 $138.8900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 0.711111 $17.7800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 4 1.622222 $81.1100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 1.355555 $33.8900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 0.511111 $25.5600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 0.466667 $23.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 1.577778 $39.4500 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 4 4 20.714285 $517.8600 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 58 64 480.571423 $12014.3000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 6 6 24.000000 $1200.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 500 528 3720.714238 $186035.8700 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 61 62 211.142851 $10557.1500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 563 595 3975.503122 $39755.0600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 38 39 229.714286 $16410.7800 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 32 36 249.428565 $14267.3300 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 27 27 197.285713 $14094.1100 $71.4400
PHY -97110HM PT SESSION BY PT ASST 20 21 113.785713 $6504.0000 $57.1600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 2.000000 $912.0000 $456.0000
SENS -V5264 EARMOLD 2 2 1.466667 $26.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 55 60 346.210714 $24733.2900 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 10.285714 $588.3400 $57.2000
SPL -92508HA GROUP SPL SESSION PER CHILD 7 7 49.714285 $690.0400 $13.8800
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Subtotal (Total Children Is Unduplicated) 683 1512 9664.451069 $330383.9300 $34.1900
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Total 1703 9793.892340 $334488.1300 $34.1500
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Number of Children (Unduplicated) With at Least One Authorization 717