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: 10-01-22 and 12-31-22 Date of Report: 01-23-23 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1235 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 5 6 2.188889 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 5 6 2.188889 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.166667 $2.4500 $14.6800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.166667 $1.2000 $7.2000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.166667 $4.8200 $28.9300
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.166667 $3.5100 $21.0400
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.027397 $1.2400 $45.3300
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.000000 $231.6200 $115.8100
EVAL -96111 DEVELOPMENTAL EVALUATION 2 2 2.000000 $100.0000 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 6 6 6.000000 $308.4600 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 11 11 11.000000 $565.5100 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 3 3 3.000000 $154.2300 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 6 6 6.000000 $308.4600 $51.4100
SCREEN-T1023 SCREENING 40 40 40.000000 $2000.0000 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 9 9 9.000000 $462.6900 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 5 5 5.000000 $257.0500 $51.4100
SPCH -92522GT EVAL OF SPCH SOUND PROD 2 2 2.000000 $102.8200 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.4100 $51.4100
SPCH -92522TLGT EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.4100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 6 6 5.433333 $279.3300 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $44.8600 $44.8600
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 2 2 1.428572 $75.6200 $52.9300
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Subtotal (Total Children Is Unduplicated) 86 102 97.555970 $5058.0900 $51.8500
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 2.733333 $136.6700 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 217 260 614.440467 $30721.9800 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 2 2 7.666666 $383.3300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 119 142 369.190478 $18459.5300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 65 77 207.533337 $10376.6900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 136 140 313.766668 $15688.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 4.366667 $109.1700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 5 5 16.390476 $819.5200 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 261 269 1306.419044 $65320.9000 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 1.033333 $51.6700 $50.0000
INTR -T1013 INTERPRETER 1 1 1.000000 $50.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 44 45 184.604762 $13284.1600 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 2 3 8.866667 $638.0500 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 18 21 94.580954 $5447.8700 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 37 37 144.810716 $10420.5800 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 4 4 21.733333 $1563.9300 $71.9600
PHY -97110HM PT SESSION BY PT ASST 8 8 28.361905 $1632.5100 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 1 1 2.000000 $115.1200 $57.5600
PHY -97110TLGTHM PT SESSION BY PT ASST 1 1 9.714286 $559.1600 $57.5600
PHY -97110TLHM PT SESSION BY PT ASST 1 1 2.100000 $120.8800 $57.5600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 2.000000 $459.2200 $229.6100
SENS -V5264 EARMOLD 1 1 0.055556 $1.0100 $18.1400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 99 101 444.340474 $31974.7400 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 10.285714 $740.1600 $71.9600
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Subtotal (Total Children Is Unduplicated) 387 1127 3797.994836 $209075.1400 $55.0500
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Total 1235 3897.739695 $214133.2300 $54.9400
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Number of Children (Unduplicated) With at Least One Authorization 405