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 741 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 19 19 19.000000 $446.5000 $23.5000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 3 3 0.877778 $44.8100 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 6 6 5.488889 $280.2100 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.388889 $19.8500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 2.000000 $102.1000 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.0500 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 3.000000 $153.1500 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 12 13 11.722222 $598.4200 $51.0500
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Subtotal (Total Children Is Unduplicated) 40 49 44.477778 $1747.1400 $39.2800
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.000000 $50.0000 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $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 252 267 1927.249211 $96362.4800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 30 31 218.178571 $15586.6600 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 11.571429 $826.6600 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 26 26 101.285716 $7235.8400 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 19.714286 $1126.8700 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 73 78 342.723810 $24484.1700 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 1 1 8.714286 $120.9500 $13.8800
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Subtotal (Total Children Is Unduplicated) 392 690 2942.190487 $161513.8200 $54.9000
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Total 741 2988.012709 $163260.9600 $54.6400
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Number of Children (Unduplicated) With at Least One Authorization 405