Summary Report for FSPSAs Ending During the Report Period Center: 10
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: 10-01-21 and 12-31-21 Date of Report: 02-04-22 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2309 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 2 2 1.344444 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 1.344444 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 312 315 314.231746 $7384.4500 $23.5000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 16 17 12.677778 $647.2000 $51.0500
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 24 24 21.755556 $1110.6200 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 5 5 3.788889 $193.4200 $51.0500
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 5 5 4.266667 $217.8200 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 4.000000 $204.2000 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 2.000000 $102.1000 $51.0500
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.0500 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 13 13 11.655556 $595.0200 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 50 51 53.500000 $2731.1800 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 3.000000 $133.6500 $44.5500
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Subtotal (Total Children Is Unduplicated) 387 442 433.876192 $13472.8000 $31.0500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 4.000000 $20000.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 2.000000 $100.0000 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 5 5 5.000000 $1150.0000 $230.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 134 141 166.298415 $8314.9400 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 0.444444 $22.2200 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 20 22 21.644444 $1082.2200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 26 28 37.143650 $1857.1800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 89 89 83.322225 $4166.1300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.900000 $47.5000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 705 761 5242.210321 $262110.5000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 200 211 1353.666673 $96705.8900 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 4 4 16.785715 $1199.1700 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 15 16 111.250002 $6363.5000 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 228 240 1310.788097 $93642.6700 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 24.642857 $1408.5900 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 3 3 24.571429 $1404.5000 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 304 325 1840.503969 $131485.5800 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 4 4 21.785714 $1556.3700 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 1.357143 $77.6300 $57.2000
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 4.000000 $285.7600 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 4 4 14.785715 $205.2300 $13.8800
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Subtotal (Total Children Is Unduplicated) 1006 1865 10288.100813 $633185.5500 $61.5500
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Total 2309 10723.321449 $646658.3500 $60.3000
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Number of Children (Unduplicated) With at Least One Authorization 1071