Summary Report for FSPSAs Ending During the Report Period Center: 52
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: 01-01-22 and 03-31-22 Date of Report: 04-16-22 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1371 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 1 1 0.588889 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 1 1 0.588889 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 3 1.700000 $24.7900 $14.5800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 3 1.700000 $16.6400 $9.7900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 3 3 1.700000 $48.8200 $28.7200
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.000000 $13.7100 $13.7100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 0.700000 $14.6200 $20.8900
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.054795 $2.4700 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.054795 $6.3000 $115.0100
EXIT -EXIT EXIT ASSESSMENT 1 1 1.000000 $50.0000 $50.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 11 11 11.000000 $561.5500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 6 6 6.000000 $306.3000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 12 12 12.000000 $612.6000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
SCREEN-T1023 SCREENING 39 42 49.428571 $2471.4300 $50.0000
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 2.000000 $102.1000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 12 12 12.666667 $646.6400 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 13 13 12.266667 $546.4800 $44.5500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 86 114 114.271495 $5475.5000 $47.9200
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 0.700000 $35.0000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 230 278 547.683328 $27384.1400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 0.750000 $18.7500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 137 163 405.499997 $20274.9900 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 67 71 157.066667 $7853.3400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 169 181 352.516661 $17625.8100 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 1.733333 $86.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.633333 $15.8300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 264 288 1274.133335 $63706.6700 $50.0000
INTR -T1013 INTERPRETER 3 3 9.790476 $489.5300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 41 43 164.371427 $11742.7000 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 1.233333 $88.1100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 16 18 87.590478 $5010.1800 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 4 5 25.880953 $1480.3900 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 45 47 180.166668 $12871.1100 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 7.428571 $424.6200 $57.1600
SENS -V5264 EARMOLD 1 1 0.222222 $4.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 134 148 698.358732 $49890.7800 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 1 2 3.514286 $48.7800 $13.8800
SPL -92508TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 4.466667 $62.0000 $13.8800
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 421 1256 3923.740467 $219113.3600 $55.8400
-------------------------------------------------------------------------------------------------------------------------------------
Total 1371 4038.600851 $224588.8600 $55.6100
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 429