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: 01-01-23 and 03-31-23 Date of Report: 04-20-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1578 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 4 4 1.933333 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 4 4 1.933333 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 48 63 49.530954 $2402.2600 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 8 8 8.144444 $456.9000 $56.1000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.450000 $6.6100 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 24 24 19.218255 $424.1500 $22.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.800000 $24.8600 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.322222 $6.7800 $21.0400
AUDE -92651 AEP HEARING STATUS DETER I&R 1 1 0.261111 $22.7000 $86.9400
AUDE -V5010 ASSESSMENT FOR HEARING AID 7 7 7.800000 $353.5000 $45.3200
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Subtotal (Total Children Is Unduplicated) 82 106 87.526986 $3697.7500 $42.2500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 16 17 22.711111 $113555.5000 $5000.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.800000 $416.9200 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 146 181 134.719444 $6735.9700 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 11 16 10.672222 $533.6100 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 26 32 57.296035 $2864.8200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 0.566667 $14.1700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 67 68 47.173014 $2358.6400 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 1 1 2.166667 $108.3400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 42 45 40.000003 $2000.0200 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 1 1 1.533333 $76.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 108 111 90.005557 $4500.2900 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 2 2 1.227777 $61.3900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 229 247 1076.868249 $53843.3900 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 26 26 140.690477 $7034.5300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 341 609 1957.265085 $19572.6500 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 20 21 103.576984 $7453.4100 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 4 5 36.333334 $2614.5400 $71.9600
OCCT -97530TL OT SESSION BY LICENSED OT 15 15 87.669840 $6308.7300 $71.9600
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 3.066667 $220.6800 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 7 8 43.485715 $3129.2300 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 2 2 6.200000 $446.1500 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 20 21 112.438096 $8091.0300 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 3 3 7.447620 $535.9400 $71.9600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 1.800000 $826.6000 $459.2200
SENS -V5264 EARMOLD 1 1 1.800000 $32.6300 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 11 11 64.638095 $4651.3500 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 5.142857 $370.0800 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 18 20 123.338098 $8875.4000 $71.9600
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Subtotal (Total Children Is Unduplicated) 384 1468 4181.632947 $257232.6300 $61.5100
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Total 1578 4271.093266 $260930.3800 $61.0900
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Number of Children (Unduplicated) With at Least One Authorization 388