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: 10-01-23 and 12-31-23 Date of Report: 01-14-24 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2232 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 20 20 10.277780 $382.3400 $37.2000
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Subtotal (Total Children Is Unduplicated) 20 20 10.277780 $382.3400 $37.2000
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 17 17 16.966667 $768.9300 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.8100 $115.8100
OCTF -97168 OT RE-EVAL EST PLAN CARE 31 35 10.655556 $547.8000 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 20 20 13.043652 $670.5800 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 15 16 6.000000 $308.4600 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 9 9 3.520636 $181.0000 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 67 74 29.111115 $1496.6200 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.4100 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $51.4100 $51.4100
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Subtotal (Total Children Is Unduplicated) 132 174 82.297626 $4192.0300 $50.9400
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 4 0.477778 $23.8900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 409 423 303.238090 $15161.9000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 43 43 59.185710 $2959.2700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 476 496 294.584122 $14729.2000 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 78 87 501.921429 $12548.0400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 642 684 4132.807944 $206640.3900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 83 93 362.000001 $26049.5300 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 5 7 56.000000 $3225.6100 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 43 49 174.285717 $12541.5900 $71.9600
PHY -97110HM PT SESSION BY PT ASST 5 6 54.000000 $3108.2400 $57.5600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 1.000000 $229.6100 $229.6100
SENS -V5264 EARMOLD 1 1 1.000000 $18.1300 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 110 125 523.000003 $37635.0700 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 13.000000 $935.4800 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 5 7 35.142859 $2024.2300 $57.6000
TRAV -TRAVS Travel by mile 10 11 57.228570 $25.4700 $0.4400
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Subtotal (Total Children Is Unduplicated) 720 2038 6568.872223 $337855.6200 $51.4300
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Total 2232 6661.447629 $342429.9900 $51.4000
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Number of Children (Unduplicated) With at Least One Authorization 756