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 1 1 0.411111 $6.9000 $16.7800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.411111 $10.0600 $24.4700
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.205556 $9.2500 $45.0100
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.205556 $23.6400 $115.0200
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Subtotal (Total Children Is Unduplicated) 1 4 1.233334 $49.8500 $40.4200
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 530 610 982.911908 $49145.6100 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 530 602 886.064287 $44303.2300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 530 602 892.836513 $44641.8600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 529 604 891.050001 $44552.5200 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 13 14 72.204761 $3610.2500 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 5 6 30.428571 $2065.4900 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 4 4 29.000000 $1968.5200 $67.8800
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 0.205556 $102.8000 $500.1100
SENS -V5264 EARMOLD 1 1 0.411111 $7.4000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 0.377778 $18.8900 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 7 7 31.730954 $2153.8900 $67.8800
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Subtotal (Total Children Is Unduplicated) 539 2454 3817.999218 $193654.2800 $50.7200
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Total 2459 3821.089695 $193704.1400 $50.6900
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Number of Children (Unduplicated) With at Least One Authorization 540