Summary Report for FSPSAs Initiated During the Report Period Center: 09
This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start 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 starting 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 2 2 0.828571 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 0.828571 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 1.266667 $21.2600 $16.7800
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 1.266667 $11.5400 $9.1100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 1.266667 $11.8300 $9.3400
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 3 1.672223 $36.3400 $21.7300
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 0.861112 $38.7500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.405556 $46.6400 $115.0100
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Subtotal (Total Children Is Unduplicated) 2 12 6.738892 $166.3600 $24.6900
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 2.888889 $144.4500 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 563 611 893.576179 $44678.7600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 564 606 892.281733 $44614.0200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 565 605 892.442845 $44622.0800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 564 610 884.096018 $44204.7400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 373 407 2229.297646 $111464.8000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 83 95 449.915877 $30540.2500 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 131 146 842.473020 $57187.0500 $67.8800
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 0.405556 $92.4800 $228.0200
SENS -V5264 EARMOLD 2 2 1.038889 $18.7000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 6 7 6.211111 $310.5600 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 172 200 850.969631 $57763.7800 $67.8800
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Subtotal (Total Children Is Unduplicated) 595 3292 7945.597394 $435641.6500 $54.8300
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Total 3306 7953.164857 $435808.0200 $54.8000
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Number of Children (Unduplicated) With at Least One Authorization 596