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 1410 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 11 11 8.363491 $311.1200 $37.2000
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Subtotal (Total Children Is Unduplicated) 11 11 8.363491 $311.1200 $37.2000
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 4.000000 $181.2800 $45.3200
OCTF -97168 OT RE-EVAL EST PLAN CARE 10 11 3.600001 $185.0800 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 4 4 4.000000 $205.6400 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 4 5 0.872223 $44.8500 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 0.450000 $23.1300 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 21 25 14.549998 $748.0100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 2.000000 $102.8200 $51.4100
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Subtotal (Total Children Is Unduplicated) 41 52 29.472222 $1490.8100 $50.5800
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
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 15.428571 $771.4300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 226 260 1611.566663 $80578.3800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 10 11 56.857142 $4091.4400 $71.9600
OCCT -97530TLGTHM OT SESSION BY OT ASST 1 1 9.428571 $543.0900 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 4 5 22.428571 $1613.9500 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 22 24 131.714286 $9478.1800 $71.9600
TRAV -TRAVS Travel by mile 13 13 106.571429 $47.4200 $0.4500
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Subtotal (Total Children Is Unduplicated) 653 1347 2670.076196 $132927.9500 $49.7800
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Total 1410 2707.911909 $134729.8800 $49.7500
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Number of Children (Unduplicated) With at Least One Authorization 665