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: 01-01-23 and 03-31-23 Date of Report: 04-20-23 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2337 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 31 31 17.730157 $659.5600 $37.2000
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Subtotal (Total Children Is Unduplicated) 31 31 17.730157 $659.5600 $37.2000
Screening, Eval, and Assessment, Class # 02
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 1.000000 $15.8400 $15.8400
AUDE -V5010 ASSESSMENT FOR HEARING AID 16 16 16.000000 $725.1200 $45.3200
OCTF -97168 OT RE-EVAL EST PLAN CARE 44 48 18.194446 $935.3800 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 22 22 12.832541 $659.7200 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 0.438889 $22.5600 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 15 18 5.061110 $260.1900 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 13 13 4.427778 $227.6300 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 0.388889 $19.9900 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 93 106 51.688885 $2657.3100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 2.505555 $128.8100 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $44.8600 $44.8600
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Subtotal (Total Children Is Unduplicated) 164 232 114.538093 $5748.8300 $50.1900
EI Services, Class # 03
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1 2 0.433334 $21.6700 $50.0100
CONOF -CONOF CONSULT, OT, FACE TO FACE 441 462 326.266673 $16313.3500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 55 56 63.560321 $3178.0200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 487 511 325.820635 $16291.0300 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 56 59 404.857144 $10121.4200 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 15.428571 $771.4300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 672 730 4813.971395 $240698.7800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 72 76 400.642856 $28830.2700 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 2.285714 $164.4800 $71.9600
OCCT -97530TLGTHM OT SESSION BY OT ASST 1 1 9.428571 $543.0900 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 35 38 185.714285 $13363.9900 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 116 123 658.709522 $47400.7400 $71.9600
TRAV -TRAVS Travel by mile 13 13 106.571429 $47.4200 $0.4500
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Subtotal (Total Children Is Unduplicated) 739 2074 7313.690450 $377745.6900 $51.6500
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Total 2337 7445.958700 $384154.0700 $51.5900
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Number of Children (Unduplicated) With at Least One Authorization 768