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: 07-01-22 and 06-30-23 Date of Report: 07-25-23 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 4984 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 20 22 33.715876 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 20 22 33.715876 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 4 5 20.000000 $293.6000 $14.6800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 4 5 20.000000 $176.2000 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 4 5 20.000000 $578.4000 $28.9200
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 4 5 20.000000 $420.8000 $21.0400
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 5 1.876711 $85.0500 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 5 3.410958 $395.0200 $115.8100
EVAL -96111 DEVELOPMENTAL EVALUATION 5 5 5.000000 $250.0000 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 19 21 21.000000 $1079.6100 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 28 32 35.733333 $1837.0500 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 7 8 8.000000 $411.2800 $51.4100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 9 9 9.000000 $462.6900 $51.4100
PSTH -97161TL PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 19 20 25.166667 $1293.8200 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
SCREEN-T1023 SCREENING 204 221 229.410045 $11470.5000 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 38 39 39.000000 $2004.9900 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 2 2 2.000000 $102.8200 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 15 16 21.200000 $1089.8900 $51.4100
SPCH -92522GT EVAL OF SPCH SOUND PROD 4 4 4.000000 $205.6400 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 2 2 2.000000 $102.8200 $51.4100
SPCH -92522TLGT EVAL OF SPCH SOUND PROD 2 2 2.000000 $102.8200 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 25 28 30.500000 $1568.0100 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 7 8 8.000000 $411.2800 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 6 10 106.476190 $5473.9400 $51.4100
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Subtotal (Total Children Is Unduplicated) 324 464 640.773904 $30176.0900 $47.0900
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 3 4 14.333334 $716.6700 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 5 5 33.033333 $1651.6700 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 560 996 5478.183342 $273909.2100 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 3 3 17.933333 $896.6700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 5.466667 $136.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 349 545 3499.423822 $174971.2500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 183 333 2282.533338 $114126.6900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 390 573 3060.050008 $153002.5400 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 3 4 22.166666 $1108.3300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 17 21 107.466668 $2686.6700 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 3.100000 $77.5000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 3.100000 $77.5000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 12 18 209.228572 $10461.4300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 676 1081 12647.605951 $632380.2300 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 4 5 33.699999 $1685.0000 $50.0000
INTR -T1013 INTERPRETER 4 5 65.014286 $3250.7100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 104 149 1357.371426 $97676.4200 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 7 9 61.719047 $4441.3100 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 42 61 760.580951 $43809.4600 $57.6000
OCCT -97530TLGTHM OT SESSION BY OT ASST 2 2 8.623810 $496.7300 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 114 183 1658.613095 $119353.8600 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 7 8 85.385715 $6144.3700 $71.9600
PHY -97110HM PT SESSION BY PT ASST 26 39 583.957142 $33612.5800 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 3 5 46.659523 $2685.7300 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 1 1 12.200000 $877.9100 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 2 2 15.100000 $1086.6000 $71.9600
PHY -97110TLGTHM PT SESSION BY PT ASST 1 1 36.000000 $2072.1600 $57.5600
PHY -97110TLHM PT SESSION BY PT ASST 1 1 5.166667 $297.4000 $57.5600
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 4.000000 $918.4400 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 1.000000 $459.2200 $459.2200
SENS -V5264 EARMOLD 4 5 6.666666 $120.8700 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 291 410 4450.472615 $320256.0000 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 15 18 255.676189 $18398.4500 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 3 17.600000 $1266.5000 $71.9600
SPL -92508HA GROUP SPL SESSION PER CHILD 2 2 12.133333 $169.3800 $13.9600
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Subtotal (Total Children Is Unduplicated) 1025 4498 36861.265498 $2025282.0800 $54.9400
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Total 4984 37535.755278 $2055458.1700 $54.7600
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Number of Children (Unduplicated) With at Least One Authorization 1056