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: 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 1124 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 1 1 0.355556 $13.2300 $37.2000
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Subtotal (Total Children Is Unduplicated) 1 1 0.355556 $13.2300 $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 5 5 1.388889 $71.4000 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 8 8 3.150000 $161.9400 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 6 6 1.244445 $63.9800 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 8 8 4.222222 $217.0600 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 23 27 9.855556 $506.6800 $51.4100
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Subtotal (Total Children Is Unduplicated) 36 58 23.861112 $1202.3400 $50.3900
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 2 0.300000 $15.0000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 297 304 261.703182 $13085.2000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 33 33 42.546030 $2127.2900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 428 445 320.804774 $16040.3000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 228 250 1706.249219 $85312.4100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 3 3 25.142857 $1809.2800 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 3 3 17.142858 $1233.6000 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 5 8 40.142859 $2888.6700 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 3 22.000001 $1267.1900 $57.6000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 6.571429 $472.8800 $71.9600
TRAV -TRAVS Travel by mile 13 13 69.338096 $30.8600 $0.4500
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Subtotal (Total Children Is Unduplicated) 551 1065 2511.941305 $124282.6700 $49.4800
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Total 1124 2536.157973 $125498.2400 $49.4800
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Number of Children (Unduplicated) With at Least One Authorization 564