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: 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 1373 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 1.688888 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 1.688888 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 2.333333 $34.0200 $14.5800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 2.333333 $22.8400 $9.7900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 2.333333 $67.0100 $28.7200
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 2.333333 $48.7400 $20.8900
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.191781 $8.6300 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.191781 $22.0600 $115.0100
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 1.000000 $50.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 2 2 2.000000 $100.0000 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 13 13 13.000000 $663.6500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 5 5 5.000000 $255.2500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 6 6 6.000000 $306.3000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
SCREEN-T1023 SCREENING 57 58 65.428571 $3271.4300 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.0500 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 3 3 3.000000 $153.1500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 13 13 13.666667 $697.6900 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 10 10 10.000000 $445.5000 $44.5500
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 7 7 29.561904 $1554.0700 $52.5700
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Subtotal (Total Children Is Unduplicated) 108 127 161.374036 $7853.4900 $48.6700
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 2.333333 $116.6700 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 252 284 624.050007 $31202.5400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 0.750000 $18.7500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 126 144 344.666668 $17233.3400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 72 81 224.833331 $11241.6600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 184 190 408.516672 $20425.8600 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 1.266667 $63.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 3.100000 $77.5000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 4 4 1.485713 $74.2900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 265 275 1385.611888 $69280.6600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 3 3 2.428571 $121.4300 $50.0000
INTR -T1013 INTERPRETER 1 1 0.533333 $26.6700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 40 42 146.419047 $10460.1700 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 2.428571 $173.5000 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 18 20 68.780953 $3934.2600 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 2 2 14.857143 $849.8300 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 50 50 207.676192 $14836.3900 $71.4400
PHY -97110HM PT SESSION BY PT ASST 5 5 49.123809 $2807.9200 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 3 3 23.228571 $1327.7500 $57.1600
SENS -V5264 EARMOLD 1 1 0.777778 $14.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 122 127 614.419036 $43894.1200 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 0.142857 $10.2100 $71.4600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 0.533333 $38.1000 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 3 4 12.733333 $176.7400 $13.8800
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Subtotal (Total Children Is Unduplicated) 458 1244 4140.696806 $228405.6700 $55.1600
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Total 1373 4303.759730 $236259.1600 $54.9000
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Number of Children (Unduplicated) With at Least One Authorization 494