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: 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 6938 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 20 21 32.900000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 20 21 32.900000 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AACIS -92597 AAC INTIAL EVAL BY LICENSED SLP 2 3 7.000000 $723.5200 $103.3600
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 169 264 292.793651 $14200.5000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 34 38 41.282040 $2315.9300 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 4 4 2.061110 $32.6500 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 2 2 1.550000 $30.2400 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 3 2.061111 $48.7900 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 4 5 3.450000 $50.6500 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 69 78 97.840476 $2159.3400 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 3 1.933333 $17.0300 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 2 1.061111 $30.6900 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 2 1.061111 $47.8300 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 3 4 5.516666 $76.1800 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 6 7 5.700000 $119.9300 $21.0400
AUDE -92650 AEP SCR AUDITORY POTENTIAL 1 1 0.872222 $53.2000 $61.0000
AUDE -92651 AEP HEARING STATUS DETER I&R 4 4 3.194444 $277.7200 $86.9400
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 2 2 1.772222 $133.1500 $75.1300
AUDE -V5010 ASSESSMENT FOR HEARING AID 31 35 33.416666 $1514.4400 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 3 1.366667 $158.2800 $115.8100
EXIT -EXIT EXIT ASSESSMENT 3 3 4.000000 $200.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 279 463 507.932830 $22190.0600 $43.6900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 68 78 114.849999 $574249.5000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 26.285714 $1314.2900 $50.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.000000 $69.3500 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 8 9 11.366665 $2632.7100 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 473 724 669.865482 $33493.3000 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 44 64 46.316670 $2315.8500 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 103 145 318.212694 $15910.6100 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 3 3 3.088889 $154.4500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 2 3.311111 $82.7800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 237 292 563.634129 $28181.7100 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 9 11 24.988889 $1249.4500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 2.333333 $58.3300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 140 192 357.127778 $17856.3900 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 1 1 1.533333 $76.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 367 504 904.084922 $45204.2500 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 4 4 6.833333 $341.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 2.205556 $55.1400 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 0.077778 $1.9500 $25.0100
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 3 13.549206 $677.4600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 694 1061 12128.297605 $606414.8700 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 75 100 1168.492855 $58424.6500 $50.0000
INTR -T1013 INTERPRETER 1 1 7.857143 $392.8600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1019 2725 20881.514258 $250578.1600 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 52 68 878.677780 $63229.6900 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 12 16 218.568254 $15728.1700 $71.9600
OCCT -97530TL OT SESSION BY LICENSED OT 64 90 1061.084123 $76355.6000 $71.9600
OCCT -97530TLGT OT SESSION BY LICENSED OT 2 2 14.485714 $1042.3900 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 45 63 765.522220 $55086.9800 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 5 6 41.604763 $2993.8800 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 72 102 1018.332540 $73279.2100 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 3 4 53.676190 $3862.5400 $71.9600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 1.944444 $223.2400 $114.8100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 5 7 9.344444 $4291.1400 $459.2200
SENS -V5264 EARMOLD 5 7 18.344445 $332.5900 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 38 46 506.477778 $36446.1500 $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 79 111 1286.444442 $92572.5300 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 3 3 38.609523 $2778.3400 $71.9600
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Subtotal (Total Children Is Unduplicated) 1056 6454 43181.515431 $2068791.4600 $47.9100
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Total 6938 43722.348261 $2090981.5100 $47.8200
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Number of Children (Unduplicated) With at Least One Authorization 1071