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 1303 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
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.144444 $2.8200 $19.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.188889 $4.1700 $22.0700
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.305556 $13.8500 $45.3300
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.305556 $35.3900 $115.8300
EXIT -EXIT EXIT ASSESSMENT 1 1 2.000000 $100.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 69 89 62.104762 $3025.5000 $48.7200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 7 8.388889 $41944.5000 $5000.0100
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 4 4 3.161111 $158.0600 $50.0000
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 1 1 4.533333 $226.6700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 2 2 8.644444 $432.2200 $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 2 2 18.966667 $1364.8400 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 1 1 4.857143 $349.5200 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 1 1 4.714286 $339.2400 $71.9600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.305556 $140.3400 $459.2900
SENS -V5264 EARMOLD 1 1 0.305556 $5.5400 $18.1300
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Subtotal (Total Children Is Unduplicated) 417 1211 2602.544458 $87073.1200 $33.4600
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Total 1303 2668.089697 $90098.6200 $33.7700
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Number of Children (Unduplicated) With at Least One Authorization 417