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: 10-01-11 and 12-31-11 Date of Report: 02-15-12 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 -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 2.000000 $30.5000 $15.2500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 2.000000 $16.5600 $8.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 2.000000 $20.7600 $10.3800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 2.000000 $42.1600 $21.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.000000 $27.1900 $27.1900
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.000000 $48.5000 $48.5000
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Subtotal (Total Children Is Unduplicated) 3 10 10.000000 $185.6700 $18.5700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $1500.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 2.000000 $100.0000 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 177 193 205.328572 $10266.4300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 7 7 7.000000 $350.0000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 14 14 14.000000 $700.0000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 174 191 203.328572 $10166.4300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 248 263 1541.742869 $77087.0400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 76 89 386.140477 $26211.2200 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 127 140 680.850001 $46216.0700 $67.8800
SCONLY-SCONLY SERVICE COORDINATION ONLY 5 5 5.319047 $5.3200 $1.0000
SENS -V5264 EARMOLD 2 2 2.000000 $36.0000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 8 8 8.000000 $400.0000 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 204 243 1282.888097 $87082.4000 $67.8800
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Subtotal (Total Children Is Unduplicated) 469 1158 4339.597635 $260120.9100 $59.9400
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Total 1168 4349.597635 $260306.5800 $59.8500
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Number of Children (Unduplicated) With at Least One Authorization 469