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: 01-01-23 and 03-31-23 Date of Report: 04-20-23 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 597 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 1.100000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 1.100000 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.566667 $8.3200 $14.6800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.566667 $4.0800 $7.2000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.566667 $16.3900 $28.9200
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.566667 $11.9200 $21.0400
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.046575 $2.1100 $45.3400
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.046575 $5.4000 $115.8700
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 1.000000 $50.0000 $50.0000
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
SCREEN-T1023 SCREENING 1 1 1.000000 $50.0000 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.4100 $51.4100
SPCH -92522GT 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
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Subtotal (Total Children Is Unduplicated) 7 12 8.359818 $353.8600 $42.3300
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 2.333333 $116.6700 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 183 209 460.950008 $23047.5400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 114 133 307.066671 $15353.3600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 71 78 200.900001 $10045.0100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 117 125 281.933338 $14096.6900 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 2 2 4.000000 $200.0000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 8 8 10.000002 $250.0100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 10 10 53.128572 $2656.4300 $50.0000
INTR -T1013 INTERPRETER 3 3 20.285714 $1014.2900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 3 6.799999 $489.3200 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 2 2 17.285714 $995.6600 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 1 1 10.000000 $719.6000 $71.9600
SENS -V5264 EARMOLD 1 1 0.188889 $3.4200 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 5 5 33.742857 $2428.1400 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 1.285714 $92.5200 $71.9600
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Subtotal (Total Children Is Unduplicated) 229 583 1409.900812 $71508.6400 $50.7200
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Total 597 1419.360630 $71862.5000 $50.6300
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Number of Children (Unduplicated) With at Least One Authorization 233