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: 10-01-13 and 12-31-13 Date of Report: 02-18-14 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
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.866667 $12.4500 $14.3600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.866667 $16.0000 $18.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.866667 $8.6800 $10.0200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 1.844445 $15.5100 $8.4100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 1.844445 $38.7300 $21.0000
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.433333 $9.5400 $22.0200
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.433333 $10.6400 $24.5500
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.433333 $19.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.433333 $49.8300 $114.9900
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Subtotal (Total Children Is Unduplicated) 2 11 8.022223 $180.8800 $22.5500
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 1.844445 $92.2300 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 947 1384 1903.194306 $95159.0300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 948 1372 1893.145896 $94656.6300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 948 1364 1896.078436 $94803.2600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 950 1384 1919.845101 $95991.5800 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 398 450 2572.666642 $128633.3400 $50.0000
INTR -INTR INTERPRETER 1 1 6.285714 $314.2900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 85 96 466.161902 $31643.0700 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 135 152 764.302376 $51880.8800 $67.8800
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 0.433333 $98.7900 $227.9800
SENS -V5264 EARMOLD 2 2 1.844445 $33.2000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 10 10 3.222222 $161.1100 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 193 215 1054.161902 $71556.5700 $67.8800
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 14 35 6766.361904 $3383.1800 $0.5000
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Subtotal (Total Children Is Unduplicated) 958 6468 19249.548624 $668407.1500 $34.7200
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Total 6479 19257.570847 $668588.0300 $34.7200
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Number of Children (Unduplicated) With at Least One Authorization 958