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: 01-01-23 and 03-31-23 Date of Report: 04-20-23 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1263 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 6 6 5.893651 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 6 6 5.893651 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 2.433333 $35.7200 $14.6800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 2.433333 $17.5200 $7.2000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 2.433333 $70.3700 $28.9200
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 2.433333 $51.2000 $21.0400
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.200000 $9.0600 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.200000 $23.1600 $115.8100
EVAL -96111 DEVELOPMENTAL EVALUATION 2 2 2.000000 $100.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 1 1 1.000000 $50.0000 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 6 6 6.000000 $308.4600 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 8 8 7.866667 $404.4300 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 4 4 4.000000 $205.6400 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 5 6 6.000000 $308.4600 $51.4100
SCREEN-T1023 SCREENING 65 66 67.000000 $3350.0000 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 13 13 13.000000 $668.3300 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.4100 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 3 4 4.000000 $205.6400 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 4.000000 $205.6400 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $44.8600 $44.8600
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 3.571429 $189.0300 $52.9300
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Subtotal (Total Children Is Unduplicated) 107 126 133.571428 $6453.1700 $48.3100
EI Services, Class # 03
CONIF -CONIF CONSULT, ITDS FACE TO FACE 211 242 559.716667 $27985.8400 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 2.166667 $108.3400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 131 148 356.433336 $17821.6800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 62 72 197.800001 $9890.0100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 122 124 267.933334 $13396.6700 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 2 2 3.666666 $183.3300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 6 6 11.799999 $295.0000 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 0.533333 $13.3300 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 5 5 16.490476 $824.5200 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 299 305 1453.409533 $72670.4800 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 4 4 14.009524 $700.4700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 37 40 177.816667 $12795.7100 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 8.371429 $602.4100 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 12 12 88.457143 $5095.1200 $57.6000
OCCT -97530TLGTHM OT SESSION BY OT ASST 1 1 2.400000 $138.2400 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 50 51 187.963098 $13525.8300 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 1 1 1.233333 $88.7500 $71.9600
PHY -97110HM PT SESSION BY PT ASST 11 12 57.985713 $3337.6600 $57.5600
SENS -V5264 EARMOLD 1 1 0.811111 $14.7100 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 91 96 431.659527 $31062.2300 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 13.161905 $947.1200 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 4.200000 $302.2300 $71.9600
SPL -92508HA GROUP SPL SESSION PER CHILD 1 1 6.700000 $93.5300 $13.9600
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Subtotal (Total Children Is Unduplicated) 458 1131 3864.719462 $211893.1900 $54.8300
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Total 1263 4004.184541 $218346.3600 $54.5300
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Number of Children (Unduplicated) With at Least One Authorization 503