Summary Report for FSPSAs Initiated During the Report Period Center: 52
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 1312 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 3 3 2.255555 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 2.255555 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 2.200000 $32.0800 $14.5800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 2.200000 $51.7000 $23.5000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 2.200000 $21.5400 $9.7900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 2.200000 $63.1800 $28.7200
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 2.200000 $45.9600 $20.8900
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.180822 $8.1400 $44.9900
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.361644 $41.5800 $114.9900
EXIT -EXIT EXIT ASSESSMENT 3 3 3.000000 $150.0000 $50.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 10 10 10.000000 $510.5000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 4 4 4.000000 $204.2000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 11 12 12.000000 $612.6000 $51.0500
SCREEN-T1023 SCREENING 36 36 36.000000 $1800.0000 $50.0000
SPCH -92522 EVAL OF SPCH SOUND PROD 3 3 3.000000 $153.1500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 10 11 11.000000 $561.5500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 9 9 9.000000 $400.9500 $44.5500
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Subtotal (Total Children Is Unduplicated) 80 95 99.542466 $4657.1300 $46.7900
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 2.200000 $110.0000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 2 1.866667 $93.3400 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 230 250 513.971422 $25698.5400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 131 149 347.499995 $17374.9800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 62 73 162.538092 $8126.8900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 171 178 358.504759 $17925.2200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 3.166667 $79.1700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 272 286 1495.757150 $74787.8800 $50.0000
INTR -T1013 INTERPRETER 2 2 1.857143 $92.8600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 45 47 194.152381 $13870.2300 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 15 15 82.066667 $4694.2100 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 3 3 19.447619 $1112.4000 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 34 36 203.107144 $14509.9700 $71.4400
PHY -97110HM PT SESSION BY PT ASST 5 5 14.428572 $824.7300 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 1 1 5.678571 $324.5900 $57.1600
SENS -V5264 EARMOLD 1 1 1.466667 $26.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 149 160 812.278572 $58029.2200 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 2 2 2.738096 $38.0000 $13.8800
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Subtotal (Total Children Is Unduplicated) 478 1214 4222.726184 $237718.6200 $56.3000
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Total 1312 4324.524205 $242375.7500 $56.0500
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Number of Children (Unduplicated) With at Least One Authorization 498