Summary Report for FSPSAs Ending During the Report Period Center: 54
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: 10-01-21 and 12-31-21 Date of Report: 02-04-22 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1514 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 5 4.900000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 5 5 4.900000 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 44 51 36.105556 $1751.1200 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 5 5 3.538889 $197.1500 $55.7100
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.733333 $10.6900 $14.5800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 2.000000 $47.0000 $23.5000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.733333 $7.1800 $9.7900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.733333 $21.0600 $28.7200
AUDE -92585 AUD EVOKED RESPONSE (COMP) 5 5 3.188889 $270.5500 $84.8400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.377778 $5.1800 $13.7100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 3 3 3.000000 $62.6700 $20.8900
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 2.533334 $114.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 2.888889 $332.2200 $115.0000
SCREEN-T1023 SCREENING 2 2 1.255556 $62.7800 $50.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.177778 $9.0800 $51.0600
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Subtotal (Total Children Is Unduplicated) 63 81 57.266668 $2890.6800 $50.4800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 11 13 17.155555 $85777.5000 $4999.9800
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 2 0.922223 $46.1200 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 4 4 0.886073 $61.0100 $68.8500
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 1.294444 $297.7100 $229.9900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 86 99 61.992456 $3099.6100 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 71 89 67.105558 $3355.2900 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 27 31 33.388887 $1669.4400 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 33 45 44.044442 $2202.2100 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 47 47 35.173014 $1758.6500 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 40 41 40.194443 $2009.7200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.200000 $55.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 33 34 28.072222 $1403.6100 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 19 19 15.150002 $757.5100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 63 64 44.746032 $2237.3000 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 52 55 45.016664 $2250.8200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.833333 $45.8300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 92 98 404.158732 $20207.9400 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 212 228 1024.585718 $51229.2600 $50.0000
INTR -T1013 INTERPRETER 1 1 2.500000 $125.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 224 392 976.167465 $9761.6700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 17 17 76.241269 $5446.6700 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 7 7 27.681746 $1977.5900 $71.4400
OCCT -97530TL OT SESSION BY LICENSED OT 2 2 5.600000 $400.0600 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 27 29 127.896823 $9136.9400 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 10 16 25.088890 $1792.3600 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 6 7 25.514286 $1822.7400 $71.4400
PHY -97110TL PT SESSION BY LICENSED PT 3 3 10.916667 $779.8900 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 27 28 102.938094 $7353.8800 $71.4400
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.755556 $344.5500 $456.0300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 9 10 40.493650 $2892.8600 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 3 11.971429 $855.2400 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 1.000000 $71.4400 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 35 37 235.261904 $16807.1000 $71.4400
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Subtotal (Total Children Is Unduplicated) 406 1428 3537.947577 $238032.4900 $67.2800
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Total 1514 3600.114245 $240923.1800 $66.9200
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Number of Children (Unduplicated) With at Least One Authorization 410