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 1152 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
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.800000 $24.8600 $13.8100
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.800000 $81.5800 $45.3200
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Subtotal (Total Children Is Unduplicated) 49 65 53.130954 $2508.6900 $47.2200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 8 8 11.000000 $55000.0000 $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 2 2 5.680953 $284.0500 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 2 2 12.785714 $639.2900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 341 609 1957.265085 $19572.6500 $10.0000
PHY -97110 PT SESSION BY LICENSED PT 1 1 6.311111 $454.1500 $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
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Subtotal (Total Children Is Unduplicated) 373 1083 2383.803582 $96480.1600 $40.4700
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Total 1152 2438.867869 $98988.8600 $40.5900
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Number of Children (Unduplicated) With at Least One Authorization 378