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: 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 1814 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 24 24 17.660318 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 4 4 3.144444 $116.3400 $37.0000
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Subtotal (Total Children Is Unduplicated) 28 28 20.804762 $116.3400 $5.5900
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 2 2 2.000000 $47.0000 $23.5000
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 1.000000 $44.7600 $44.7600
AUDE -V5010 ASSESSMENT FOR HEARING AID 5 6 5.066667 $228.0000 $45.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 12 13 15.108730 $771.3100 $51.0500
OCTF -97168TLGT OT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.0500 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 15 15 9.933334 $507.1000 $51.0500
OCTH -97165TLGT OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 28 29 27.265873 $1391.9200 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 3 3 0.549999 $28.0700 $51.0400
PSTH -97163 PT EVAL HIGH COMPLEXITY 6 6 2.444444 $124.7900 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 22 23 37.119046 $1894.9100 $51.0500
SPCH -92521GT EVAL OF SPEECH FLUENCY 3 3 2.283333 $116.5600 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 13 14 12.117461 $618.6000 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 21 22 31.185714 $1389.3300 $44.5500
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Subtotal (Total Children Is Unduplicated) 95 139 148.074601 $7264.4600 $49.0600
EI Services, Class # 03
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 0.188889 $13.0100 $68.8600
AUD -92633 AUD REHAB POSTLING HEARING LOSS 3 4 4.000000 $275.4400 $68.8600
AUDE -V5160 DISPENSING FEE BINAURAL 9 9 12.571429 $2891.4200 $230.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 359 372 384.150789 $19207.5200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.033333 $0.8300 $24.9800
CONPF -CONPF CONSULT, PT, FACE TO FACE 44 48 54.387300 $2719.3700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 431 445 401.118248 $20055.8800 $50.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 4 4 34.142856 $853.5800 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 22 22 244.571426 $6114.2900 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 4 4 36.714286 $1835.7100 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 577 616 3995.199944 $199760.2000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 16 17 164.285715 $1642.8600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 37 41 226.070633 $16150.5200 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 3 3 24.285715 $1389.1400 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 8 8 27.817461 $1987.2800 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 0.285714 $20.4100 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 44 46 328.640477 $23478.0800 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 6.285714 $359.5400 $57.2000
TRAV -TRAVS Travel by mile 3 4 19.800000 $8.8100 $0.4500
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Subtotal (Total Children Is Unduplicated) 609 1647 5964.549929 $298763.8700 $50.0900
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Total 1814 6133.429292 $306144.6700 $49.9100
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Number of Children (Unduplicated) With at Least One Authorization 628