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: 07-01-22 and 06-30-23 Date of Report: 07-25-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 6947 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 22 24 44.267459 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 22 24 44.267459 $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 175 274 323.346825 $15682.3200 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 32 36 38.220929 $2144.2000 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 0.450000 $7.1300 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 6 6 5.561112 $108.5000 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.650000 $15.3900 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 6 6 4.883334 $71.6900 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 66 76 89.534922 $1976.0400 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 4 4 4.983333 $43.9000 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 2.616667 $75.6800 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 0.650000 $29.3000 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 4 5 7.305555 $100.8900 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 9 9 6.050000 $127.2900 $21.0400
AUDE -92651 AEP HEARING STATUS DETER I&R 2 2 1.322222 $114.9500 $86.9400
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 1 1 0.900000 $67.6200 $75.1300
AUDE -V5010 ASSESSMENT FOR HEARING AID 24 28 30.088889 $1363.6300 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 3 1.577778 $182.7300 $115.8100
EXIT -EXIT EXIT ASSESSMENT 4 4 6.000000 $300.0000 $50.0000
SCREEN-T1023 SCREENING 2 2 1.844445 $92.2300 $50.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 280 462 527.986011 $22710.1900 $43.0100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 61 74 128.346824 $641733.5000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 8 8 32.957936 $1647.9000 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 1.197260 $83.0300 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 9 11 13.327777 $3086.9600 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 462 735 678.609930 $33930.5400 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 54 74 51.805558 $2590.2900 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 106 134 337.940476 $16897.0200 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 20 21 35.177777 $1758.8900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.866667 $46.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 247 304 627.880955 $31394.0600 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 27 27 37.683334 $1884.1700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 9 10 35.332538 $883.3100 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 137 182 375.149997 $18757.4900 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 15 16 14.951588 $747.5800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 348 455 885.806349 $44290.3200 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 32 35 26.850795 $1342.5500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 8 8 6.838889 $170.9700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 5 5 44.228572 $2211.4300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 684 1073 12308.745235 $615437.1700 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 151 179 1484.958732 $74247.9200 $50.0000
INTR -T1013 INTERPRETER 1 2 25.571429 $1278.5700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 991 2594 21061.792056 $252741.4700 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 51 69 931.687303 $67044.2300 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 10 15 211.584127 $15225.5800 $71.9600
OCCT -97530TL OT SESSION BY LICENSED OT 65 80 927.891271 $66771.0400 $71.9600
OCCT -97530TLGT OT SESSION BY LICENSED OT 9 10 43.253174 $3112.4900 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 49 63 836.864284 $60220.7500 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 5 5 38.271430 $2754.0200 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 70 102 1001.784923 $72088.4300 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 12 13 69.536509 $5003.8500 $71.9600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 1.944444 $223.2400 $114.8100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 4 6 10.400000 $4775.8900 $459.2200
SENS -V5264 EARMOLD 5 7 12.422222 $225.2100 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 33 43 569.050793 $40948.8900 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 11.571429 $832.6800 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 65 89 1266.519047 $91138.7100 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 6 7 61.314286 $4412.1800 $71.9600
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 1065 6461 44211.115916 $2181938.9700 $49.3500
-------------------------------------------------------------------------------------------------------------------------------------
Total 6947 44783.369386 $2204649.1600 $49.2300
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 1076