Summary Report for FSPSAs Initiated During the Report Period Center: 54
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: 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 906 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 9 9 10.344443 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 9 9 10.344443 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 47 54 32.738887 $1587.8300 $48.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.666667 $15.6700 $23.5000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.355556 $16.0000 $45.0100
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.355556 $40.8900 $115.0100
EXIT -EXIT EXIT ASSESSMENT 3 3 4.000000 $200.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 52 60 38.116666 $1860.3900 $48.8100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 8 9 13.988889 $69944.5000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 4 4 0.455556 $22.7800 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.355556 $24.4900 $68.8700
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 73 87 55.035515 $2751.7800 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 85 104 70.766671 $3538.3600 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 26 27 28.620633 $1431.0300 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 38 45 58.538890 $2926.9500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 43 43 37.613491 $1880.6800 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 44 45 41.100001 $2055.0100 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 20 20 29.170636 $1458.5400 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 18 18 14.500002 $725.0100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 45 45 45.143653 $2257.1900 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 64 66 56.334131 $2816.7300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 5 3.977777 $99.4400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1 1 2.355556 $117.7800 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 2.355556 $117.7800 $50.0000
INTR -T1013 INTERPRETER 1 2 10.071429 $503.5700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 204 312 906.313489 $9063.1400 $10.0000
OCCT -97530TLGT OT SESSION BY LICENSED OT 2 2 12.504762 $893.3400 $71.4400
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Subtotal (Total Children Is Unduplicated) 330 837 1389.202193 $102628.0700 $73.8800
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Total 906 1437.663302 $104488.4600 $72.6800
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Number of Children (Unduplicated) With at Least One Authorization 339