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: 07-01-24 and 09-30-24 Date of Report: 04-06-25 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1452 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 22.588888 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 15 15 22.588888 $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 -97802 NUTRITIONAL EVAL, INITIAL 2 2 19.714286 $985.7100 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 10 11 38.519046 $1925.9600 $50.0000
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 7 9 51.571428 $2996.8200 $58.1100
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Subtotal (Total Children Is Unduplicated) 20 31 114.004763 $6079.2600 $53.3200
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 125 192 253.787117 $12689.3600 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 58 73 72.294372 $1807.3700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 94 103 82.344442 $4117.2100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.000000 $25.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 50 55 48.388889 $2419.4500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.000000 $25.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 33 35 27.422221 $1371.1100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 51 53 50.433332 $2521.6600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 613 733 4792.719036 $258806.8900 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 43 48 307.971426 $25044.2300 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 4 4 17.857143 $1162.8600 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 44 49 264.326187 $21495.0100 $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 52 57 374.500000 $30454.3200 $81.3200
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Subtotal (Total Children Is Unduplicated) 668 1406 6294.977499 $362055.0800 $57.5100
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Total 1452 6431.571150 $368134.3300 $57.2400
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Number of Children (Unduplicated) With at Least One Authorization 683