Summary Report for FSPSAs Initiated During the Report Period Statewide
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: 04-01-14 and 06-30-14 Date of Report: 08-18-14 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 1.011111 $14.5200 $14.3600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.011111 $18.6600 $18.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.011111 $10.1300 $10.0200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.011111 $8.5000 $8.4100
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 1.011111 $7.8400 $7.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.011111 $21.2300 $21.0000
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.011111 $63.3300 $62.6300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.011111 $22.2600 $22.0200
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.011111 $60.6700 $60.0000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 0.472222 $22.9000 $48.5000
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Subtotal (Total Children Is Unduplicated) 2 10 9.572221 $250.0500 $26.1200
EI Services, Class # 03
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 5.285715 $132.1400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 6 6 30.428570 $1521.4400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 8.857143 $601.2200 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 5 5 19.857143 $1347.9100 $67.8800
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 3 4.285715 $290.9100 $67.8800
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 1 1 13.000000 $130.0000 $10.0000
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Subtotal (Total Children Is Unduplicated) 10 19 81.714286 $4023.6200 $49.2400
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Total 29 91.286507 $4273.6600 $46.8200
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Number of Children (Unduplicated) With at Least One Authorization 11