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: 01-01-24 and 03-31-24 Date of Report: 04-04-25 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1362 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 15 15 29.238096 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 15 15 29.238096 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.466667 $10.0200 $21.4600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.466667 $12.1500 $26.0400
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.466667 $7.5400 $16.1500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.466667 $3.7000 $7.9200
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.466667 $14.8500 $31.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.466667 $10.8000 $23.1400
AUDE -92651 AEP HEARING STATUS DETER I&R 1 1 0.466667 $36.5200 $78.2600
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.466667 $21.1500 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.466667 $54.0500 $115.8200
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 5 6 42.857141 $2142.8700 $50.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $58.1100 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 10 12 79.428572 $4615.6000 $58.1100
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Subtotal (Total Children Is Unduplicated) 16 28 127.485716 $6987.3400 $54.8100
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 136 197 242.099242 $12104.9800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 69 91 87.546960 $2188.6800 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 80 82 68.147619 $3407.3800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 34 34 29.225395 $1461.2600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 26 26 22.383333 $1119.1700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 46 46 42.461110 $2123.0500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 566 641 4143.123788 $223728.7900 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 52 61 295.555557 $24034.5800 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 3 3 20.571429 $1339.6100 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 53 60 276.478569 $22483.2600 $81.3200
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.466667 $107.1600 $229.6300
SENS -V5264 EARMOLD 1 1 0.466667 $8.4600 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 67 76 433.334914 $35238.8500 $81.3200
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Subtotal (Total Children Is Unduplicated) 633 1319 5661.861250 $329345.2300 $58.1700
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Total 1362 5818.585062 $336332.5700 $57.8000
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Number of Children (Unduplicated) With at Least One Authorization 647