Summary Report for FSPSAs Initiated During the Report Period Center: 09
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: 01-01-23 and 03-31-23 Date of Report: 04-20-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1388 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 18 18 19.226984 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 18 18 19.226984 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.005556 $0.1100 $19.6700
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.005556 $0.1300 $23.8700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.005556 $0.0800 $14.7900
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.005556 $0.0400 $7.2500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.005556 $0.1600 $29.1600
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.005556 $0.1200 $21.2000
AUDE -92651 AEP HEARING STATUS DETER I&R 1 1 0.005556 $0.4900 $87.6300
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.005556 $0.2500 $45.6800
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.005556 $0.6500 $116.7200
NUTR -97802 NUTRITIONAL EVAL, INITIAL 2 2 8.104762 $405.2400 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 9 9 32.719047 $1635.9600 $50.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 12 20 40.873813 $2043.2200 $49.9900
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 121 173 209.745644 $10487.2800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 91 124 128.998831 $3224.9700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 50 51 39.600001 $1980.0100 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 27 28 23.688888 $1184.4400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.438889 $10.9700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 18 18 13.144444 $657.2200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 40 41 30.122222 $1506.1100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 1.294445 $32.3600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 571 633 3902.599962 $195130.2100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 58 73 394.816663 $28411.0200 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 5.571429 $400.9200 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 60 69 406.594045 $29258.5200 $71.9600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.005556 $0.6400 $115.7100
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.005556 $1.2900 $231.4300
SENS -V5264 EARMOLD 1 1 0.005556 $0.1000 $18.2700
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 118 132 839.381738 $60401.9900 $71.9600
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 684 1350 5996.013869 $332688.0500 $55.4800
-------------------------------------------------------------------------------------------------------------------------------------
Total 1388 6056.114666 $334731.2700 $55.2700
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 699