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
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 5 5 1.850000 $34.1500 $18.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 5 5 1.850000 $18.5400 $10.0200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 6 6 2.827778 $23.7800 $8.4100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 6 6 2.827778 $59.3800 $21.0000
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 3 3 1.288888 $28.3800 $22.0200
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.433333 $10.6400 $24.5500
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 1.044443 $46.9900 $44.9900
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 0.722221 $83.0400 $114.9800
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Subtotal (Total Children Is Unduplicated) 6 34 13.711108 $317.3500 $23.1500
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 6 6 3.022222 $151.1100 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1470 2152 2919.888685 $145993.4300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1470 2136 2912.556944 $145626.8800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1471 2123 2908.245036 $145411.2600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1472 2162 2943.272813 $147162.6500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 543 622 3428.399974 $171420.0300 $50.0000
INTR -INTR INTERPRETER 1 1 6.285714 $314.2900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 132 152 711.097614 $48269.3100 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 201 224 1162.427769 $78905.6700 $67.8800
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 0.044444 $22.2000 $499.5000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 0.677777 $154.5200 $227.9700
SENS -V5264 EARMOLD 5 6 2.661111 $47.9000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 18 18 7.344444 $367.2200 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 395 449 2248.242049 $152610.7500 $67.8800
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 19 51 7887.561904 $3943.7800 $0.5000
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Subtotal (Total Children Is Unduplicated) 1485 10105 27141.728500 $1040400.9800 $38.3300
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Total 10139 27155.439608 $1040718.3300 $38.3200
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Number of Children (Unduplicated) With at Least One Authorization 1485