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: 10-01-22 and 12-31-22 Date of Report: 01-23-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1785 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 3 3 3.440477 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 3.440477 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 67 84 59.160317 $2869.2700 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 9 9 7.333333 $411.4000 $56.1000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 5 5 2.488889 $48.5600 $19.5100
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 3 1.061111 $15.5800 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 16 16 7.744443 $170.9200 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 3 1.777777 $12.8000 $7.2000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.944444 $27.3100 $28.9200
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.338889 $4.6800 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 2.000000 $42.0800 $21.0400
AUDE -V5010 ASSESSMENT FOR HEARING AID 8 9 6.755556 $306.1600 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 2 0.416667 $48.2600 $115.8200
EXIT -EXIT EXIT ASSESSMENT 1 1 2.000000 $100.0000 $50.0000
SCREEN-T1023 SCREENING 1 1 0.533333 $26.6700 $50.0000
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Subtotal (Total Children Is Unduplicated) 99 137 92.554759 $4083.6800 $44.1200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 15 16 21.986508 $109932.5000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 4 4 3.161111 $158.0600 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 2.338889 $541.7400 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 157 190 134.458731 $6722.9300 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 21 23 19.466667 $973.3400 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 40 43 42.216668 $2110.8400 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 2 2 0.722222 $36.1100 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 83 84 76.844446 $3842.2300 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 3 3 3.566667 $178.3400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 7.571429 $189.2900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 47 47 36.555557 $1827.7900 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 3 3 0.766667 $38.3400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 116 119 85.105557 $4255.2900 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 2 2 0.666667 $33.3400 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 13.819047 $690.9500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 256 275 1228.666669 $61433.3300 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 25 25 139.336507 $6966.8200 $50.0000
INTR -T1013 INTERPRETER 1 2 12.428572 $621.4300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 385 672 2128.297623 $21282.9700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 20 21 131.711111 $9477.9400 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 14.780953 $1063.6400 $71.9600
OCCT -97530TL OT SESSION BY LICENSED OT 23 23 126.049207 $9070.5000 $71.9600
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 2.285714 $164.4800 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 18 18 81.276193 $5848.6200 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 2 2 4.747619 $341.6400 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 27 30 90.158729 $6487.8100 $71.9600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 3 3 1.927778 $885.2800 $459.2300
SENS -V5264 EARMOLD 3 3 2.872223 $52.0700 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 9 9 49.417459 $3556.0700 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 15 16 106.984127 $7698.5800 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 1.133333 $81.5500 $71.9600
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Subtotal (Total Children Is Unduplicated) 423 1645 4571.320650 $266563.7700 $58.3100
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Total 1785 4667.315886 $270647.4500 $57.9900
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Number of Children (Unduplicated) With at Least One Authorization 425