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: 07-01-22 and 06-30-23 Date of Report: 07-25-23 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 10013 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
SCONLY-SCONLY *SERVICE COORDINATION ONLY 17 17 37.466668 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 107 119 138.433331 $5149.7100 $37.2000
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Subtotal (Total Children Is Unduplicated) 124 136 175.899999 $5149.7100 $29.2800
Screening, Eval, and Assessment, Class # 02
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 4 4 4.000000 $63.3600 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 5 5 5.000000 $97.5500 $19.5100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.200000 $26.4800 $22.0700
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.000000 $28.9200 $28.9200
AUDE -V5010 ASSESSMENT FOR HEARING AID 75 82 81.355556 $3687.0400 $45.3200
OCTF -97168 OT RE-EVAL EST PLAN CARE 129 189 143.865875 $7396.1500 $51.4100
OCTF -97168TLGT OT RE-EVAL EST PLAN CARE 1 2 2.000000 $102.8200 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 9 9 5.866666 $301.6000 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 159 160 161.535718 $8304.5700 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 0.816667 $41.9900 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 4 4 2.316666 $119.1000 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 54 80 54.535714 $2803.6800 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 59 60 79.850000 $4105.0900 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 3 3 1.866667 $95.9700 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 0.222222 $11.4200 $51.4000
PSTH -97163TLGT PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 269 435 374.050004 $19229.9200 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 2 2 1.571429 $80.7900 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 38 57 31.611114 $1625.1400 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 10 16 11.933335 $613.5000 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 2 31.857143 $1637.7800 $51.4100
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Subtotal (Total Children Is Unduplicated) 520 1116 998.454776 $50475.6900 $50.5500
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 2.000000 $100.0000 $50.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 0.855556 $59.3400 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 14.571429 $3375.0300 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 4 2.050000 $102.5000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1 4 2.577778 $128.8900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1190 1780 3535.541248 $176776.9900 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 158 244 711.040476 $35552.0100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1379 2003 3445.029346 $172251.3500 $50.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 4 4 56.285713 $1407.1500 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 188 388 4431.957137 $110798.9400 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 6 7 104.423809 $5221.2000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1889 2951 46957.014321 $2347850.6800 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 2 10.285715 $514.2900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 15 15 181.571428 $2178.8600 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 243 451 3927.584932 $282628.9500 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 21.857143 $1572.8400 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 5 10 37.490475 $2159.4500 $57.6000
OCCT -97530TLGTHM OT SESSION BY OT ASST 1 2 20.285714 $1168.4600 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 104 221 1909.000003 $137371.6200 $71.9600
PHY -97110HM PT SESSION BY PT ASST 4 6 33.571429 $1932.3600 $57.5600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 323 595 6267.893252 $451037.6200 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 5.571429 $400.9200 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 3.285714 $189.2600 $57.6000
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 1 2 30.285715 $1744.4600 $57.6000
TRAV -TRAVS Travel by mile 43 64 981.734920 $436.8700 $0.4400
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Subtotal (Total Children Is Unduplicated) 1972 8761 72693.764682 $3736959.9900 $51.4100
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Total 10013 73868.119457 $3792585.3900 $51.3400
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Number of Children (Unduplicated) With at Least One Authorization 2032