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: 10-01-23 and 12-31-23 Date of Report: 01-14-24 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1156 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 0.888889 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 0.888889 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 1.766667 $25.9400 $14.6800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 1.766667 $15.5600 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 1.766667 $51.0900 $28.9200
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 1.766667 $37.1700 $21.0400
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 0.145206 $6.5800 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 0.145206 $16.8200 $115.8100
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 3 3 3.000000 $154.2300 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 3 3 3.000000 $154.2300 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
SCREEN-T1023 SCREENING 37 37 37.000000 $1850.0000 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 8 8 8.000000 $411.2800 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.4100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 2.000000 $102.8200 $51.4100
SPCH -92610GT EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $51.4100 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 0.600000 $30.8500 $51.4100
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Subtotal (Total Children Is Unduplicated) 62 72 66.957080 $3165.0300 $47.2700
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 2 2.666667 $133.3400 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 188 233 633.652375 $31682.5900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 119 129 374.152376 $18707.6000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 73 87 248.966663 $12448.3200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 118 120 329.699993 $16484.9700 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 1 1 2.466667 $123.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 6 6 6.457143 $161.4300 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 3 19.676190 $983.8100 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 277 283 1291.204766 $64560.2200 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 6 6 20.100000 $1005.0000 $50.0000
INTR -T1013 INTERPRETER 1 1 0.700000 $35.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 30 30 172.190481 $12390.8400 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 3 3 13.495237 $971.1100 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 9 9 25.561904 $1472.3700 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 52 54 145.172619 $10446.6100 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 2 2 5.166666 $371.7900 $71.9600
PHY -97110HM PT SESSION BY PT ASST 14 14 106.192858 $6112.4600 $57.5600
PHY -97110TLGT PT SESSION BY LICENSED PT 2 2 5.033333 $362.2000 $71.9600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 1.000000 $459.2200 $459.2200
SENS -V5264 EARMOLD 2 2 0.588889 $10.6800 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 90 92 358.076190 $25767.1600 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 12.285714 $884.0800 $71.9600
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Subtotal (Total Children Is Unduplicated) 425 1082 3774.506731 $205574.1000 $54.4600
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Total 1156 3842.352700 $208739.1200 $54.3300
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Number of Children (Unduplicated) With at Least One Authorization 438