Summary Report for FSPSAs Ending During the Report Period Center: 09
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: 04-01-23 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 1304 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 17 17 32.206348 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 17 17 32.206348 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.072222 $1.4100 $19.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.072222 $1.7100 $23.6600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.072222 $1.0600 $14.6800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.072222 $0.6400 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.072222 $2.0900 $28.9100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.072222 $1.5200 $21.0300
AUDE -92651 AEP HEARING STATUS DETER I&R 1 1 0.072222 $6.2800 $86.9100
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.072222 $3.2700 $45.3100
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.072222 $8.3600 $115.7700
NUTR -97802 NUTRITIONAL EVAL, INITIAL 3 3 12.157143 $607.8600 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 8 8 35.209525 $1760.4700 $50.0000
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Subtotal (Total Children Is Unduplicated) 12 20 48.016666 $2394.6600 $49.8700
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 103 146 190.093423 $9504.6700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 84 116 109.871847 $2746.8000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 55 57 42.748412 $2137.4200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 3 0.588889 $14.7200 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 39 40 33.100793 $1655.0400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 18 18 11.777777 $588.8900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 43 44 36.027778 $1801.3900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 5 2.100000 $52.5000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 530 606 3600.033341 $180001.5000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 57 68 360.235716 $25922.5300 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 39 43 295.276193 $21248.0500 $71.9600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.072222 $8.2900 $114.7800
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.072222 $16.5800 $229.5400
SENS -V5264 EARMOLD 1 1 0.072222 $1.3100 $18.1200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 102 118 705.802384 $50789.5000 $71.9600
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Subtotal (Total Children Is Unduplicated) 613 1267 5387.873219 $296489.1800 $55.0300
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Total 1304 5468.096233 $298883.8300 $54.6600
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Number of Children (Unduplicated) With at Least One Authorization 628