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
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 7 7 7.000000 $106.7500 $15.2500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 7 7 7.000000 $57.9600 $8.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 8 8 8.000000 $83.0400 $10.3800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 7 7 7.000000 $147.5600 $21.0800
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 1.000000 $22.9600 $22.9600
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.000000 $51.7600 $51.7600
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 3 3 3.000000 $81.5700 $27.1900
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 4.000000 $180.0000 $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) 9 42 42.000000 $1125.1000 $26.7900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 11 11 11.000000 $16500.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 8 8 8.000000 $400.0000 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 217 242 277.952381 $13897.6300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 23 24 26.000000 $1300.0000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 18 19 20.833333 $1041.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 210 236 266.152381 $13307.6200 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 368 413 2259.842871 $112992.0700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 205 236 1089.730959 $73970.8900 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 247 275 1241.545256 $84276.0100 $67.8800
PHY -97110HM PT SESSION BY PT ASST 1 1 1.000000 $54.3200 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 14 14 14.585714 $14.5900 $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 8 8 8.000000 $144.0000 $18.0000
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 1 1.000000 $50.0000 $50.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 17 17 17.000000 $850.0000 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 473 540 2852.045240 $193596.8100 $67.8800
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Subtotal (Total Children Is Unduplicated) 825 2048 8097.688135 $512916.5900 $63.3400
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Total 2090 8139.688135 $514041.6900 $63.1500
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Number of Children (Unduplicated) With at Least One Authorization 825