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: 10-01-23 and 12-31-23 Date of Report: 01-14-24 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1502 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 6 6 5.433333 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 0.733333 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 7 7 6.166666 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AACIS -92597 AAC INTIAL EVAL BY LICENSED SLP 2 2 3.000000 $310.0800 $103.3600
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 55 62 53.744445 $2606.6100 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 9 9 8.122223 $455.6600 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 3 3 1.883333 $29.8300 $15.8400
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.083333 $1.9700 $23.6600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.083333 $1.2200 $14.6700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 10 10 5.605555 $123.7100 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 0.555555 $4.8900 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.083333 $2.4100 $28.9100
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 2 1.083333 $48.8400 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 0.594444 $8.2100 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 0.555555 $11.6900 $21.0400
AUDE -92650 AEP SCR AUDITORY POTENTIAL 1 1 0.472222 $28.8000 $61.0000
AUDE -92651 AEP HEARING STATUS DETER I&R 2 2 1.472222 $127.9900 $86.9400
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 1 1 0.472222 $35.4800 $75.1300
AUDE -V5010 ASSESSMENT FOR HEARING AID 10 10 5.688888 $257.8200 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.083333 $9.6500 $115.7600
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Subtotal (Total Children Is Unduplicated) 85 112 83.583329 $4064.8600 $48.6300
EI Services, Class # 03
AACFIT-92609 AAC FITTING, ADJUST, TRAINING VISIT 1 1 0.933333 $39.5800 $42.4100
ASST -ASST ASSISTIVE TECHNOLOGY 16 20 28.566667 $142833.5000 $5000.0100
AUDE -V5160 DISPENSING FEE BINAURAL 5 5 3.394444 $786.2100 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 143 174 125.397621 $6269.9000 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 6 6 3.983333 $199.1700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 35 38 34.362700 $1718.1400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 52 54 36.505554 $1825.2700 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 2 2 3.033333 $151.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.666667 $16.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 48 48 34.011110 $1700.5500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 114 120 71.893647 $3594.6700 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 1 1 0.022222 $1.1100 $49.9500
CONSP -CONSP CONSULT, SLP, PHONE 2 2 1.033334 $25.8400 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 5.142857 $257.1500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 250 277 1204.738101 $60236.9400 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 25 25 134.784129 $6739.2100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 258 450 1199.088887 $14389.0700 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 29 30 160.047619 $11517.0300 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 5 5 35.025397 $2520.4300 $71.9600
OCCT -97530TL OT SESSION BY LICENSED OT 29 33 145.717465 $10485.8200 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 17 18 52.521428 $3779.4300 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 2 2 11.000000 $791.5600 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 27 27 116.915873 $8413.2800 $71.9600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.511111 $58.6800 $114.8100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 3 3 1.849999 $849.5100 $459.2000
SENS -V5264 EARMOLD 3 3 3.616666 $65.5700 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 13 14 48.615871 $3498.4000 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 8.000000 $575.6800 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 20 20 62.712697 $4512.8100 $71.9600
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Subtotal (Total Children Is Unduplicated) 428 1383 3535.092065 $287877.8200 $81.4300
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Total 1502 3624.842060 $291942.6800 $80.5400
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Number of Children (Unduplicated) With at Least One Authorization 434