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: 10-01-23 and 12-31-23 Date of Report: 01-14-24 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1434 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 24 25 51.026984 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 24 25 51.026984 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.033333 $0.6500 $19.4900
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.033333 $0.7900 $23.6500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.033333 $0.4900 $14.6600
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.033333 $0.2900 $8.8000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.033333 $0.9600 $28.8900
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.033333 $0.7000 $21.0200
AUDE -92651 AEP HEARING STATUS DETER I&R 1 1 0.033333 $2.9000 $86.8500
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.033333 $1.5100 $45.2800
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.033333 $3.8600 $115.7000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 4.571429 $228.5700 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 6 7 18.119047 $905.9600 $50.0000
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 10 10 65.857142 $3385.7200 $51.4100
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Subtotal (Total Children Is Unduplicated) 18 27 88.847615 $4532.3900 $51.0100
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 130 191 231.098079 $11554.9200 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 87 123 122.824379 $3070.6100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 68 73 60.172223 $3008.6200 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 41 42 49.615873 $2480.7900 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 25 25 18.944443 $947.2200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 31 33 38.182540 $1909.1300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.094444 $2.3600 $24.9900
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 624 701 4536.995242 $226849.8400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 55 60 362.600000 $26092.7000 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 35 40 267.109523 $19221.2100 $71.9600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.033333 $3.8200 $114.7000
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.033333 $7.6500 $229.3800
SENS -V5264 EARMOLD 1 1 0.033333 $0.6000 $18.1100
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 83 90 629.078571 $45268.5400 $71.9600
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Subtotal (Total Children Is Unduplicated) 693 1382 6316.815316 $340417.9900 $53.8900
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Total 1434 6456.689915 $344950.3800 $53.4300
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Number of Children (Unduplicated) With at Least One Authorization 716