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 5014 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
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Subtotal (Total Children Is Unduplicated) 22 24 44.267459 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 175 273 322.346825 $15633.8200 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 4 4 4.866667 $273.0200 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 0.450000 $7.1300 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 2 2 1.305556 $25.4700 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.650000 $15.3900 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.650000 $9.5400 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 1.350000 $29.7900 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.650000 $5.7300 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.650000 $18.8000 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 0.650000 $29.3000 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 3 6.427777 $88.7700 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.650000 $13.6800 $21.0400
AUDE -92651 AEP HEARING STATUS DETER I&R 1 1 0.450000 $39.1200 $86.9400
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 4 6.733333 $305.1500 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 2 0.955556 $110.6700 $115.8200
EXIT -EXIT EXIT ASSESSMENT 4 4 6.000000 $300.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 186 302 354.785714 $16905.3800 $47.6500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 30 33 50.022223 $250111.5000 $5000.0100
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 8 8 32.957936 $1647.9000 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 2 3 6.116666 $1416.7300 $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 348 454 884.273016 $44213.6600 $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 4 4 31.657143 $1582.8600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 11 15 191.215874 $9560.7900 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 3 3 67.357143 $3367.8600 $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 4 5 60.315873 $4340.3300 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 1.133333 $81.5500 $71.9600
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 1.571429 $113.0800 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 3 4 63.120635 $4542.1700 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 3 3 52.571429 $3783.0300 $71.9600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 4 6.733333 $3092.0700 $459.2200
SENS -V5264 EARMOLD 2 4 6.733333 $122.0700 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 3 30.423810 $2189.3000 $71.9600
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Subtotal (Total Children Is Unduplicated) 1049 4688 24803.655165 $694588.4200 $28.0000
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Total 5014 25202.708338 $711493.8100 $28.2300
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Number of Children (Unduplicated) With at Least One Authorization 1059