Summary Report for FSPSAs Ending During the Report Period Statewide
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: 10-01-14 and 12-31-14 Date of Report: 01-12-15 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 -V5090 DISPENSING FEE PER HEARING AID 1 1 0.866667 $99.6700 $115.0000
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Subtotal (Total Children Is Unduplicated) 1 1 0.866667 $99.6700 $115.0000
EI Services, Class # 03
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1 1 1.000000 $50.0000 $50.0000
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 1 1 1.000000 $10.0000 $10.0000
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Subtotal (Total Children Is Unduplicated) 1 2 2.000000 $60.0000 $30.0000
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Total 3 2.866667 $159.6700 $55.7000
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Number of Children (Unduplicated) With at Least One Authorization 2