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: 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 1379 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 23 23 65.522225 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 23 23 65.522225 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.433333 $8.4500 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.433333 $10.2600 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.433333 $6.3600 $14.6800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.433333 $3.8200 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.433333 $12.5300 $28.9200
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.433333 $9.1200 $21.0400
AUDE -92651 AEP HEARING STATUS DETER I&R 1 1 0.433333 $37.6700 $86.9300
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.433333 $19.6400 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.433333 $50.1800 $115.8000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 7 7 40.080951 $2004.0500 $50.0000
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 6 6 52.857142 $2717.3900 $51.4100
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Subtotal (Total Children Is Unduplicated) 13 22 96.838090 $4879.4600 $50.3900
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 106 153 197.555328 $9877.7700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 82 114 107.077402 $2676.9300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 80 82 70.233332 $3511.6600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 0.233333 $5.8300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 43 45 42.594444 $2129.7200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 25 25 19.822222 $991.1100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 41 42 37.722222 $1886.1100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 2.066666 $51.6700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 610 674 4520.109519 $226005.6600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 60 66 447.019045 $32167.5400 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 36 39 231.863490 $16684.9100 $71.9600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.433333 $49.7500 $114.8000
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.433333 $99.4900 $229.5900
SENS -V5264 EARMOLD 1 1 0.433333 $7.8600 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 76 87 573.926190 $41299.7400 $71.9600
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Subtotal (Total Children Is Unduplicated) 675 1334 6251.523192 $337445.7400 $53.9800
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Total 1379 6413.883507 $342325.2000 $53.3700
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Number of Children (Unduplicated) With at Least One Authorization 696