Summary Report for FSPSAs Initiated During the Report Period Center: 52
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 740 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 2 2 1.688888 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 1.688888 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 2 2 2.000000 $100.0000 $50.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
SCREEN-T1023 SCREENING 4 4 4.000000 $200.0000 $50.0000
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $44.5500 $44.5500
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 5.142857 $270.3600 $52.5700
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Subtotal (Total Children Is Unduplicated) 11 12 16.142857 $819.1100 $50.7400
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 2.333333 $116.6700 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 251 283 623.716674 $31185.8700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 0.750000 $18.7500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 125 143 344.100001 $17205.0100 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 71 80 224.266664 $11213.3200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 183 189 407.950005 $20397.5300 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 1.266667 $63.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 3.100000 $77.5000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 11 11 54.023808 $2701.1900 $50.0000
INTR -T1013 INTERPRETER 1 1 0.533333 $26.6700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 3 3 14.371429 $1026.6900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 2.000000 $114.4000 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 3 3 18.761904 $1340.3500 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 4.266667 $243.8800 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 6 6 36.847620 $2632.3900 $71.4400
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Subtotal (Total Children Is Unduplicated) 321 726 1738.288105 $88363.5400 $50.8300
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Total 740 1756.119850 $89182.6500 $50.7800
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Number of Children (Unduplicated) With at Least One Authorization 326