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: 10-01-22 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 1677 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 2 2 2.094445 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 2.094445 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 42 62 55.081748 $2671.4800 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 12 12 11.283333 $632.9900 $56.1000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.055556 $1.0800 $19.5300
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.055556 $1.3200 $23.6900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.055556 $0.8200 $14.6900
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 17 17 14.416667 $318.1800 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.055556 $0.4000 $7.2100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.055556 $1.6100 $28.9400
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 0.055556 $2.5100 $45.1100
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 0.400000 $5.5200 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 4 4 2.500000 $52.6000 $21.0400
AUDE -V5010 ASSESSMENT FOR HEARING AID 7 8 4.761112 $215.7800 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 2 0.361112 $41.8300 $115.8400
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Subtotal (Total Children Is Unduplicated) 71 113 89.137308 $3946.1100 $44.2700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 20 25 36.161111 $180805.5000 $5000.0000
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 1.344444 $311.3900 $231.6100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 161 185 139.214285 $6960.7000 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 17 19 18.450000 $922.5000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 29 31 26.199204 $1309.9500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 58 60 53.971431 $2698.5800 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 1 1 0.900000 $45.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.133333 $3.3300 $24.9900
CONPF -CONPF CONSULT, PT, FACE TO FACE 48 50 37.877777 $1893.8900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 108 116 81.555551 $4077.7600 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 0.666667 $33.3400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 245 261 1328.737315 $66436.8500 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 24 24 135.442858 $6772.1400 $50.0000
INTR -T1013 INTERPRETER 1 1 7.857143 $392.8600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 375 657 2262.657147 $22626.5500 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 15 16 98.468252 $7085.7700 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 4 4 12.695237 $913.5500 $71.9600
OCCT -97530TL OT SESSION BY LICENSED OT 18 19 98.328572 $7075.7300 $71.9600
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 2.285714 $164.4800 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 14 14 90.893650 $6540.6900 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 1 1 2.733333 $196.6900 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 25 27 116.498412 $8383.2100 $71.9600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.344444 $39.5400 $114.8000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 2 0.361112 $165.8700 $459.3300
SENS -V5264 EARMOLD 1 2 0.361112 $6.5500 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 10 10 59.926985 $4312.3500 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 6.428571 $462.6000 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 29 29 150.282539 $10814.3200 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 1.571429 $113.0800 $71.9600
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Subtotal (Total Children Is Unduplicated) 394 1562 4772.347628 $341564.7500 $71.5700
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Total 1677 4863.579381 $345510.8600 $71.0400
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Number of Children (Unduplicated) With at Least One Authorization 396