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: 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 1805 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 4.211111 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 4 4 4.211111 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AACIS -92597 AAC INTIAL EVAL BY LICENSED SLP 1 1 2.000000 $206.7200 $103.3600
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 58 74 63.665870 $3087.7800 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 7 7 9.200000 $516.1200 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 3 3 0.788889 $12.5000 $15.8400
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.000000 $14.6800 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 26 26 25.634923 $565.7700 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.366667 $2.6400 $7.2000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.366667 $7.7200 $21.0400
AUDE -92650 AEP SCR AUDITORY POTENTIAL 1 1 0.366667 $22.3700 $61.0100
AUDE -92651 AEP HEARING STATUS DETER I&R 2 2 0.650000 $56.5100 $86.9400
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 2 2 0.777778 $58.4400 $75.1300
AUDE -V5010 ASSESSMENT FOR HEARING AID 7 7 4.688889 $212.5000 $45.3200
EXIT -EXIT EXIT ASSESSMENT 1 1 2.000000 $100.0000 $50.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 96 127 111.506350 $4863.7300 $43.6200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 15 16 17.972222 $89861.0000 $4999.9900
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.000000 $69.3500 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 1.366667 $316.5600 $231.6300
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 149 182 152.475399 $7623.7800 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 13 17 11.016666 $550.8300 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 35 44 45.525398 $2276.2800 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 2 2 1.000000 $50.0000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 0.433333 $10.8300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 87 89 55.133333 $2756.6700 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 6 6 3.855555 $192.7800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 42 46 31.527779 $1576.4000 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 1 1 1.533333 $76.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 135 144 103.223812 $5161.2000 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 0.133333 $6.6700 $49.9900
CONSP -CONSP CONSULT, SLP, PHONE 2 2 1.444444 $36.1100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 256 272 1292.004751 $64600.3100 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 20 20 70.397619 $3519.8700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 375 709 2101.496817 $21014.9900 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 16 16 97.542856 $7019.1800 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 3 4 26.495239 $1906.5900 $71.9600
OCCT -97530TL OT SESSION BY LICENSED OT 24 25 130.342855 $9379.4800 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 14 14 56.434126 $4061.0000 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 1 1 0.300000 $21.5900 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 17 18 91.151587 $6559.2600 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 1 1 4.333333 $311.8200 $71.9600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 2.733333 $1255.1900 $459.2100
SENS -V5264 EARMOLD 2 2 4.466667 $80.9800 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 8 9 40.047618 $2881.8300 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 25 26 122.607145 $8822.8200 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 0.266667 $19.1900 $71.9700
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 394 1674 4468.261887 $242019.1900 $54.1600
-------------------------------------------------------------------------------------------------------------------------------------
Total 1805 4583.979348 $246882.9200 $53.8600
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 396