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 1021 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
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 55 62 53.744445 $2606.6100 $48.5000
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 1 1 0.083333 $1.8400 $22.0600
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.083333 $0.7300 $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) 1 1 0.083333 $1.1500 $13.8000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.083333 $1.7500 $21.0300
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.083333 $3.7800 $45.3000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.083333 $9.6500 $115.7600
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Subtotal (Total Children Is Unduplicated) 57 73 55.577775 $2679.9400 $48.2200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 9 10 14.894444 $74472.0000 $4999.9900
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 -T1027SC EI INDIVIDUAL SESSION BY EI PROF 22 23 100.373017 $5018.6600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 258 450 1199.088887 $14389.0700 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 3 3 11.133334 $801.1600 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 9.600000 $690.8200 $71.9600
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 2.666667 $191.9000 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 1 1 7.733333 $556.4900 $71.9600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.083333 $38.2500 $459.0400
SENS -V5264 EARMOLD 1 1 0.083333 $1.5100 $18.1200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 3 14.561904 $1047.8700 $71.9600
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Subtotal (Total Children Is Unduplicated) 343 941 1672.127773 $112735.7000 $67.4200
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Total 1021 1733.872214 $115415.6400 $66.5700
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Number of Children (Unduplicated) With at Least One Authorization 351