Summary Report for FSPSAs Ending During the Report Period Center: 10
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 3979 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
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 0.866667 $32.2400 $37.2000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 2 2 0.866666 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 1.733333 $32.2400 $18.6000
Screening, Eval, and Assessment, Class # 02
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 2 2 2.000000 $31.6800 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 308 317 316.755556 $6179.9000 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 4 4 4.000000 $94.6800 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 265 272 271.188889 $3981.0500 $14.6800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 261 267 266.188889 $2345.1200 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 257 263 262.188889 $7582.5000 $28.9200
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 3 3 3.000000 $41.4300 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 258 264 263.188889 $5537.4900 $21.0400
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 66 69 69.000000 $5183.9700 $75.1300
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 4.000000 $181.2800 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 4.000000 $463.2400 $115.8100
NUTR -97802 NUTRITIONAL EVAL, INITIAL 4 5 4.300000 $215.0000 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 41 45 43.855555 $2254.6100 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.4100 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 16 17 17.000000 $873.9700 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 69 84 82.260317 $4229.0000 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 2 2 1.142857 $58.7600 $51.4100
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Subtotal (Total Children Is Unduplicated) 458 1623 1616.069841 $39356.5100 $24.3500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 4.000000 $20000.0000 $5000.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 201 264 283.893655 $14194.7200 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 30 34 40.122221 $2006.1100 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 73 91 71.744442 $3587.2100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 113 133 140.709528 $7035.4900 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 4 4 11.369048 $568.4500 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 0.177778 $8.8900 $50.0100
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 707 912 5854.094475 $292704.7300 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 24.857143 $1242.8600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 219 263 1509.490480 $108622.8700 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 222 269 1244.490473 $89553.4400 $71.9600
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 3.000000 $688.8300 $229.6100
SENS -V5264 EARMOLD 2 2 3.000000 $54.3900 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 304 373 2155.678586 $155122.5200 $71.9600
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Subtotal (Total Children Is Unduplicated) 1013 2353 11346.627829 $695390.4900 $61.2900
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Total 3979 12964.431003 $734779.2500 $56.6800
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Number of Children (Unduplicated) With at Least One Authorization 1187