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 1213 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 1 1 0.733333 $27.1300 $37.0000
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Subtotal (Total Children Is Unduplicated) 25 25 18.393651 $27.1300 $1.4800
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 1.000000 $23.5000 $23.5000
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 1.000000 $44.7600 $44.7600
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 2 1.066667 $48.0000 $45.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 2 3 1.238889 $63.2500 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 6 6 4.138889 $211.2900 $51.0500
OCTH -97165TLGT OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 11 11 8.649207 $441.5400 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 4 4 1.083333 $55.3000 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 10 10 25.780158 $1316.0700 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 9 10 10.811905 $551.9500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 9 10 21.374603 $952.2400 $44.5500
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Subtotal (Total Children Is Unduplicated) 37 59 77.143651 $3758.9600 $48.7300
EI Services, Class # 03
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 2.000000 $137.7200 $68.8600
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 5.571429 $1281.4200 $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 1 1 10.428571 $260.7200 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 4 4 36.714286 $1835.7100 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 191 215 1261.996805 $63099.9200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 16 17 164.285715 $1642.8600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 5 5 36.142857 $2582.0500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 8.571429 $490.2800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 1 1 4.142857 $295.9700 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 9 10 99.000000 $7072.5600 $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) 553 1129 2494.629333 $121051.1500 $48.5200
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Total 1213 2590.166635 $124837.2400 $48.2000
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Number of Children (Unduplicated) With at Least One Authorization 580