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: 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 2402 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 13 13 9.611111 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 11 11 7.227778 $267.4300 $37.0000
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Subtotal (Total Children Is Unduplicated) 23 24 16.838889 $267.4300 $15.8800
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $55.7100 $55.7100
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 2 2.000000 $89.5200 $44.7600
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 4 4 2.166667 $110.6500 $51.0700
AUDE -V5010 ASSESSMENT FOR HEARING AID 8 9 8.066667 $363.0000 $45.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 5 6 2.055557 $104.9400 $51.0500
OCTH -97165TLGT OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 69 71 51.094446 $2608.3800 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 4 4 1.494445 $76.2900 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 13 13 3.750001 $191.4400 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 4 4 2.327778 $118.8300 $51.0500
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 48 49 41.955556 $2141.8300 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 28 28 16.780159 $747.5600 $44.5500
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Subtotal (Total Children Is Unduplicated) 124 193 134.691276 $6710.2700 $49.8200
EI Services, Class # 03
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 2 2.000000 $137.7200 $68.8600
AUDE -V5160 DISPENSING FEE BINAURAL 3 4 4.000000 $920.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 2 0.877778 $43.8900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 322 339 326.932534 $16346.6400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.033333 $0.8300 $24.9800
CONPF -CONPF CONSULT, PT, FACE TO FACE 44 49 61.473806 $3073.6800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 406 423 320.947619 $16047.4000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.066667 $1.6700 $25.0100
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 74 75 519.285711 $12982.1500 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 0.755556 $37.7800 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 574 605 3875.987318 $193799.2900 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 0.714286 $35.7200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 464 472 3032.992073 $30329.9100 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 79 81 312.584128 $22331.0300 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 8 8 59.785714 $3419.7500 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 26 27 119.214290 $8516.6600 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 2 7.000000 $500.0800 $71.4400
PHY -97110HM PT SESSION BY PT ASST 4 4 23.214286 $1326.9200 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 81 82 342.071430 $24437.5800 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 5 5 21.571429 $1233.8800 $57.2000
SPL -92508HA GROUP SPL SESSION PER CHILD 1 1 12.714286 $176.4700 $13.8800
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Subtotal (Total Children Is Unduplicated) 656 2185 9044.222244 $335699.0400 $37.1200
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Total 2402 9195.752409 $342676.7400 $37.2600
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Number of Children (Unduplicated) With at Least One Authorization 681