Summary Report for FSPSAs Initiated During the Report Period Center: 10
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: 10-01-21 and 12-31-21 Date of Report: 02-04-22 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 999 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
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 23 23 32.285714 $758.7100 $23.5000
OCTH -97167 OT EVAL HIGH COMPLEXITY 14 15 26.714286 $1363.7700 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 5 5 3.511111 $179.2400 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 18 19 17.388889 $887.7000 $51.0500
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Subtotal (Total Children Is Unduplicated) 54 62 79.900000 $3189.4200 $39.9200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.000000 $50.0000 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 2.000000 $460.0000 $230.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 193 203 225.562707 $11278.1800 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 0.577778 $28.8900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 40 41 36.588892 $1829.4600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 35 35 47.901589 $2395.0900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 126 127 127.111114 $6355.5700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 254 301 2234.809524 $111740.4400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 57 61 400.499999 $28611.7400 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 3 3 29.071428 $1662.8900 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 43 45 281.321427 $20097.5900 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 5.285714 $302.1300 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 102 111 650.284125 $46456.3500 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 3 3 18.285715 $253.8000 $13.8800
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Subtotal (Total Children Is Unduplicated) 478 937 4061.300012 $236522.1200 $58.2400
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Total 999 4141.200012 $239711.5500 $57.8800
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Number of Children (Unduplicated) With at Least One Authorization 485