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
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 5 5 1.788889 $30.0200 $16.7800
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 5 5 1.788889 $16.3000 $9.1100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 5 5 1.788889 $16.7100 $9.3400
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 4 5 2.094445 $45.5100 $21.7300
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 0.100000 $2.5300 $25.2600
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 0.422222 $10.3300 $24.4700
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 1.550001 $69.7500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 1.661111 $191.0300 $115.0000
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Subtotal (Total Children Is Unduplicated) 6 31 11.194446 $382.1700 $34.1400
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 5.522222 $276.1100 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 883 967 1388.092855 $69404.6400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 883 961 1386.215076 $69310.7400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 884 958 1379.209521 $68960.4600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 884 971 1387.541265 $69377.0500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 518 569 3077.480205 $153873.8800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 153 179 850.065876 $57702.3900 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 204 229 1258.344449 $85416.4100 $67.8800
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 0.272222 $136.1000 $499.9600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.049315 $3.2000 $64.9800
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 1.238889 $282.4700 $228.0000
SENS -V5264 EARMOLD 5 5 2.516666 $45.3000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 16 18 12.800001 $640.0100 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 380 443 2129.750597 $144567.3500 $67.8800
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Subtotal (Total Children Is Unduplicated) 945 5309 12879.099159 $719996.0900 $55.9000
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Total 5342 12891.122176 $720378.2700 $55.8800
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Number of Children (Unduplicated) With at Least One Authorization 946