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: 01-01-23 and 03-31-23 Date of Report: 04-20-23 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2388 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
TCM -T1017TL TARGETED CASE MANAGEMENT 30 32 21.319045 $793.0600 $37.2000
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Subtotal (Total Children Is Unduplicated) 30 32 21.319045 $793.0600 $37.2000
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 18 18 18.000000 $815.7600 $45.3200
OCTF -97168 OT RE-EVAL EST PLAN CARE 44 47 20.266666 $1041.9100 $51.4100
OCTF -97168TLGT OT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.4100 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.316667 $16.2800 $51.4200
OCTH -97167 OT EVAL HIGH COMPLEXITY 44 44 27.333333 $1405.2100 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 0.161111 $8.2800 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 20 22 5.366668 $275.9100 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 14 14 5.866667 $301.6100 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 0.388889 $19.9900 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 122 133 71.555562 $3678.7000 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 9 9 4.388891 $225.6400 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 1.216667 $54.5800 $44.8600
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 5.571429 $294.8900 $52.9300
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Subtotal (Total Children Is Unduplicated) 224 295 162.432550 $8241.5900 $50.7400
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.000000 $50.0000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1 2 0.566666 $28.3300 $49.9900
CONOF -CONOF CONSULT, OT, FACE TO FACE 412 429 287.877774 $14393.8700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 65 67 66.793652 $3339.6800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 448 470 274.884921 $13744.2500 $50.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 2.571429 $64.2900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 71 74 511.428573 $12785.7200 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 11.285714 $564.2900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 658 712 4392.131739 $219606.6400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 91 98 450.030954 $32384.2200 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 10.571429 $760.7200 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 1 1 0.900000 $51.8400 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 39 43 181.000000 $13024.7700 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 133 140 734.428572 $52849.4700 $71.9600
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 1 1 4.000000 $230.4000 $57.6000
TRAV -TRAVS Travel by mile 18 19 87.649205 $39.0000 $0.4400
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Subtotal (Total Children Is Unduplicated) 742 2061 7017.120628 $363917.4600 $51.8600
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Total 2388 7200.872223 $372952.1100 $51.7900
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Number of Children (Unduplicated) With at Least One Authorization 800