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: 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 1426 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 16 27.411111 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 15 16 27.411111 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.544444 $11.6800 $21.4600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.544444 $14.1800 $26.0400
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.544444 $8.7900 $16.1500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.544444 $4.3100 $7.9200
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.544444 $17.3200 $31.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.544444 $12.6000 $23.1400
AUDE -92651 AEP HEARING STATUS DETER I&R 1 1 0.544444 $42.6000 $78.2400
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.544444 $24.6700 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.544444 $63.0500 $115.8000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 3 3 6.209525 $310.4800 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 11 11 72.152380 $3607.6200 $50.0000
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 7 8 69.857142 $4059.4000 $58.1100
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Subtotal (Total Children Is Unduplicated) 21 31 153.119043 $8176.6900 $53.4000
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 142 204 250.127020 $12506.3700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 68 88 83.546960 $2088.6800 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 85 93 71.769048 $3588.4600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 47 48 44.913491 $2245.6700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 29 29 21.983333 $1099.1700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 52 52 46.405555 $2320.2800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.311111 $7.7800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 594 670 4282.442908 $231251.7400 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 48 56 302.683337 $24614.1700 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 8 9 44.142858 $2874.5800 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 48 55 430.238097 $34986.9800 $81.3200
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.544444 $125.0000 $229.5900
SENS -V5264 EARMOLD 1 1 0.544444 $9.8700 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 66 72 476.383339 $38739.4500 $81.3200
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Subtotal (Total Children Is Unduplicated) 657 1379 6056.035945 $356458.1700 $58.8600
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Total 1426 6236.566099 $364634.8700 $58.4700
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Number of Children (Unduplicated) With at Least One Authorization 670