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: 01/01/10 and 03/31/10 Date of Report: 05-17-10 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 -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.00 $8.83 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.00 $10.80 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.00 $21.79 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.00 $54.38 $54.38
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.00 $31.81 $31.81
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 1.16 $69.34 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.00 $119.60 $119.60
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Subtotal (Total Children Is Unduplicated) 3 9 8.16 $363.35 $44.55
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 4 4 4.21 $210.72 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 14 14 13.47 $673.34 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 20 22 21.03 $1051.67 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 14 16 26.00 $1300.24 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 24 24 42.43 $2121.43 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 214 274 1260.84 $63042.17 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 164 210 1113.12 $75558.89 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.57 $85.36 $54.32
PHY -97110 PT SESSION BY LICENSED PT 190 243 1190.46 $80808.32 $67.88
RSPT -RSPT RESPITE 1 1 1.00 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 20 21 19.63 $19.63 $1.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 1.00 $237.12 $237.12
SENS -V5264 EARMOLD 3 3 2.16 $40.35 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 5 5 5.00 $250.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 318 439 2023.60 $137362.12 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 3.14 $41.49 $13.20
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Subtotal (Total Children Is Unduplicated) 563 1279 5728.68 $362802.84 $63.33
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Total 1288 5736.84 $363166.19 $63.30
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Number of Children (Unduplicated) With at Least One Authorization 563