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: 10-01-22 and 12-31-22 Date of Report: 01-23-23 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1427 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 4 4 3.144445 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 14 14 7.844443 $291.8100 $37.2000
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Subtotal (Total Children Is Unduplicated) 18 18 10.988888 $291.8100 $26.5500
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.000000 $90.6400 $45.3200
OCTF -97168 OT RE-EVAL EST PLAN CARE 9 9 4.383334 $225.3500 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 9 9 6.344445 $326.1700 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 5 6 3.844445 $197.6500 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 1.050000 $53.9800 $51.4100
PSTH -97163TLGT PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 29 30 18.900794 $971.7000 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 0.861111 $44.2700 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 4 3.272222 $146.7900 $44.8600
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Subtotal (Total Children Is Unduplicated) 52 68 42.656351 $2159.3600 $50.6200
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.428571 $99.2700 $231.6400
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 3 1.016667 $50.8400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 414 439 364.388886 $18219.4000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 55 58 71.546029 $3577.2900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 482 506 379.088886 $18954.4200 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 0.857143 $21.4300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 255 280 1849.341276 $92467.0400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 4 4 41.142857 $411.4300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 6 6 41.142858 $2960.6400 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 1 1 11.000000 $633.6000 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 5 6 32.428571 $2333.5600 $71.9600
PHY -97110HM PT SESSION BY PT ASST 1 1 3.428571 $197.3500 $57.5600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 19 21 146.214284 $10521.5800 $71.9600
TRAV -TRAVS Travel by mile 12 14 52.655555 $23.4300 $0.4400
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Subtotal (Total Children Is Unduplicated) 664 1341 2994.680154 $150471.2600 $50.2500
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Total 1427 3048.325393 $152922.4300 $50.1700
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Number of Children (Unduplicated) With at Least One Authorization 690