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: 01-01-13 and 03-31-13 Date of Report: 05-17-13 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
Service Coordination, Class # 01
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 1.857143 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 1.857143 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 0.600000 $10.0700 $16.7800
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 0.600000 $5.4700 $9.1100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 0.600000 $5.6000 $9.3400
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 0.600000 $13.0400 $21.7300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 0.505555 $12.3700 $24.4700
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 0.300000 $13.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 0.300000 $34.5000 $115.0000
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Subtotal (Total Children Is Unduplicated) 2 14 3.505555 $94.5500 $26.9700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.211111 $1055.5000 $4999.7400
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 0.566667 $28.3400 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 531 612 985.511908 $49275.6100 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 531 604 888.664287 $44433.2300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 530 602 892.836513 $44641.8600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 530 606 893.650001 $44682.5200 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 372 420 2422.283311 $121114.2300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 79 91 416.518247 $28273.2800 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 140 156 823.741258 $55915.6100 $67.8800
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 0.205556 $102.8000 $500.1100
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 0.094444 $21.5200 $227.8900
SENS -V5264 EARMOLD 2 2 0.600000 $10.8000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 9 9 13.968254 $698.4100 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 181 206 1013.798576 $68816.7200 $67.8800
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Subtotal (Total Children Is Unduplicated) 594 3312 8352.650133 $459070.4000 $54.9600
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Total 3327 8358.012831 $459164.9500 $54.9400
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Number of Children (Unduplicated) With at Least One Authorization 595