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: 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 10471 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 125 132 150.096032 $5583.5700 $37.2000
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Subtotal (Total Children Is Unduplicated) 125 132 150.096032 $5583.5700 $37.2000
Screening, Eval, and Assessment, Class # 02
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 5 5 5.000000 $79.2000 $15.8400
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.000000 $28.9200 $28.9200
AUDE -V5010 ASSESSMENT FOR HEARING AID 75 84 84.000000 $3806.8800 $45.3200
OCTF -97168 OT RE-EVAL EST PLAN CARE 120 186 131.651589 $6768.2100 $51.4100
OCTF -97168TLGT OT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.4100 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 1.894444 $97.3900 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 157 158 163.424604 $8401.6600 $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 47 77 55.680160 $2862.5200 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 56 57 75.883333 $3901.1600 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 4 4 2.866667 $147.3800 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 0.222222 $11.4200 $51.4000
SPCH -92521 EVAL OF SPEECH FLUENCY 275 475 354.977781 $18249.4200 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 0.571429 $29.3800 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 21 29 22.000001 $1131.0300 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 4 6 5.150000 $264.7600 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 10.142857 $521.4500 $51.4100
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Subtotal (Total Children Is Unduplicated) 497 1094 919.598420 $46564.6900 $50.6400
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 2.000000 $100.0000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 3 1.766667 $88.3400 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1 6 3.311112 $165.5600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1337 1922 3502.359494 $175117.8300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 163 250 698.877776 $34943.8700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1509 2121 3432.897574 $171644.6600 $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 173 400 4329.885681 $108247.1300 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 6 7 137.857142 $6892.8600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 2019 3103 47780.295169 $2389015.1800 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 3.571429 $178.5700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 231 462 4109.423808 $295714.2900 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 2 37.142857 $2672.8000 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 4 6 24.919046 $1435.3400 $57.6000
OCCT -97530TLGTHM OT SESSION BY OT ASST 1 2 20.285714 $1168.4600 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 105 238 1935.999999 $139314.6500 $71.9600
PHY -97110HM PT SESSION BY PT ASST 2 2 7.785714 $448.1400 $57.5600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 331 646 6578.284904 $473373.6900 $71.9600
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 1 1 14.714286 $847.5400 $57.6000
TRAV -TRAVS Travel by mile 46 67 1058.128572 $470.8700 $0.4500
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Subtotal (Total Children Is Unduplicated) 2133 9245 73735.792657 $3803246.9100 $51.5800
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Total 10471 74805.487109 $3855395.1700 $51.5400
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Number of Children (Unduplicated) With at Least One Authorization 2178