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: 04/01/10 and 06/30/10 Date of Report: 08-17-10 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
Service Coordination, Class # 01
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1 0.14 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 1 1 0.14 $0.00 $0.00
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 -V5010 ASSESSMENT FOR HEARING AID 2 2 1.01 $47.32 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.00 $239.20 $119.60
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Subtotal (Total Children Is Unduplicated) 2 9 8.01 $414.13 $51.69
EI Services, Class # 03
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 0.07 $4.59 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 4 4 3.82 $190.95 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 17 17 16.47 $823.34 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 18 18 18.45 $922.62 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 17 17 37.40 $1870.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 18 19 47.36 $2367.86 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 1.00 $73.42 $73.42
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 4.29 $214.29 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 265 295 1256.53 $62826.69 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 203 232 943.74 $64060.96 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.00 $54.32 $54.32
PHY -97110 PT SESSION BY LICENSED PT 232 267 1163.24 $78960.94 $67.88
RSPT -RSPT RESPITE 1 1 1.00 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 18 20 20.00 $20.00 $1.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.00 $65.00 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 4 4 2.08 $38.90 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 8 9 8.13 $406.67 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 379 435 1892.07 $128433.38 $67.88
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Subtotal (Total Children Is Unduplicated) 679 1345 5419.64 $341808.15 $63.07
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Total 1355 5427.79 $342222.28 $63.05
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Number of Children (Unduplicated) With at Least One Authorization 680