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: 10-01-11 and 12-31-11 Date of Report: 02-15-12 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
Services Cpt Code Number of Number of Total Units Total Cost of Avg Fee
Children Records Authorized Auth Services Per Unit Auth
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 5 5 5.000000 $76.2500 $15.2500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 5 5 5.000000 $41.4000 $8.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 5 5 5.000000 $51.9000 $10.3800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 5 5 5.000000 $105.4000 $21.0800
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.000000 $51.7600 $51.7600
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 2.000000 $54.3800 $27.1900
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 3.000000 $135.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 3.000000 $345.0000 $115.0000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.000000 $48.5000 $48.5000
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Subtotal (Total Children Is Unduplicated) 6 30 30.000000 $909.5900 $30.3200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 5 5.000000 $7500.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 5.000000 $250.0000 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 143 158 184.428572 $9221.4300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 13 13 13.000000 $650.0000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 9 10 10.000000 $500.0000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 131 148 172.295238 $8614.7700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 248 275 1519.076204 $75953.7400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 102 115 564.571436 $38323.0800 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 141 156 752.726203 $51094.9900 $67.8800
SCONLY-SCONLY SERVICE COORDINATION ONLY 10 10 10.585714 $10.5900 $1.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.000000 $65.0000 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 2.000000 $456.0000 $228.0000
SENS -V5264 EARMOLD 5 5 5.000000 $90.0000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 11 11 11.000000 $550.0000 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 261 291 1516.300004 $102926.4400 $67.8800
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Subtotal (Total Children Is Unduplicated) 506 1205 4771.983371 $296206.0200 $62.0700
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Total 1235 4801.983371 $297115.6100 $61.8700
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Number of Children (Unduplicated) With at Least One Authorization 506