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: 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 1014 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 9 9 7.622223 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 9 9 7.622223 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AACIS -92597 AAC INTIAL EVAL BY LICENSED SLP 2 2 1.344445 $138.9700 $103.3600
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 46 53 48.428571 $2348.7900 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 5 5 2.877778 $161.4400 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 0.100000 $1.5800 $15.8400
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.427778 $10.1300 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.427778 $6.2800 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 15 15 7.744445 $170.9200 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.427778 $3.7700 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.427778 $12.3700 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 2 1.427778 $64.3700 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 0.938889 $12.9700 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.427778 $9.0000 $21.0400
AUDE -92651 AEP HEARING STATUS DETER I&R 1 1 1.000000 $86.9400 $86.9400
AUDE -V5010 ASSESSMENT FOR HEARING AID 13 13 10.072222 $456.4700 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.427778 $49.5400 $115.8200
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Subtotal (Total Children Is Unduplicated) 74 100 76.500796 $3533.5400 $46.1900
EI Services, Class # 03
AACFIT-92609 AAC FITTING, ADJUST, TRAINING VISIT 5 5 3.133334 $132.8900 $42.4100
AACFIT-92609TL AAC FITTING, ADJUST, TRAINING VISIT 1 1 1.011111 $42.8800 $42.4100
ASST -ASST ASSISTIVE TECHNOLOGY 19 19 24.033333 $120166.5000 $4999.9900
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 0.611111 $141.5400 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 141 166 123.553176 $6177.6800 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 3 3 3.000000 $150.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 23 24 19.490477 $974.5300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 52 52 158.256350 $7912.8300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 -2.550000 $-63.7500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 46 48 32.601586 $1630.0700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 78 87 61.148408 $3057.4000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 -1.916666 $-47.9200 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 6 6 31.588890 $789.7300 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 5.466667 $273.3400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 241 258 1195.998425 $59799.8900 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 16 16 20.485714 $1024.2800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 39 73 205.696824 $2468.3600 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 23 26 125.814285 $9053.6000 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 17.285714 $1243.8800 $71.9600
OCCT -97530TL OT SESSION BY LICENSED OT 44 54 248.379369 $17873.3600 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 11 12 44.380951 $3193.6400 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 15 16 80.007937 $5757.3800 $71.9600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 2 2 0.711111 $81.6400 $114.8100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.427778 $196.4500 $459.2400
SENS -V5264 EARMOLD 2 2 0.527778 $9.5700 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 14 15 76.252382 $5487.1200 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 8 9 41.014286 $2951.3900 $71.9600
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Subtotal (Total Children Is Unduplicated) 374 905 2517.410331 $250503.2700 $99.5100
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Total 1014 2601.533350 $254036.8100 $97.6500
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Number of Children (Unduplicated) With at Least One Authorization 383