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: 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 2784 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 1 1 0.466667 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 0.466667 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 1.000000 $15.1900 $15.1900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 194 197 197.000000 $4227.6200 $21.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 169 173 173.000000 $2793.9500 $16.1500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 168 172 172.000000 $1362.2400 $7.9200
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 167 171 171.000000 $5439.5100 $31.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 168 172 171.122222 $3959.7700 $23.1400
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.3200 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.8100 $115.8100
NUTR -97802 NUTRITIONAL EVAL, INITIAL 4 4 5.177778 $258.8900 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 40 47 47.000000 $2731.1700 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 12 12 11.888889 $690.8600 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 51 55 54.366667 $3159.2500 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $58.1100 $58.1100
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Subtotal (Total Children Is Unduplicated) 271 1007 1006.555556 $24857.6900 $24.7000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 8 9 11.428571 $57143.0000 $5000.0100
CONIF -CONIF CONSULT, ITDS FACE TO FACE 153 184 187.780947 $9389.0300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 22 28 23.411112 $1170.5600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 49 55 38.699997 $1934.9900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 112 124 135.390475 $6769.5300 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 4.571429 $228.5700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 630 718 4348.453174 $234816.4900 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 160 189 1139.714289 $92681.5700 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 193 229 1064.419047 $86558.5600 $81.3200
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 1.000000 $229.6100 $229.6100
SENS -V5264 EARMOLD 1 1 1.000000 $18.1300 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 193 237 1284.909518 $104488.8500 $81.3200
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Subtotal (Total Children Is Unduplicated) 903 1776 8240.778559 $595428.8700 $72.2500
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Total 2784 9247.800782 $620286.5600 $67.0700
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Number of Children (Unduplicated) With at Least One Authorization 979