Summary Report for FSPSAs Initiated During the Report Period Center: 10
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
Service Coordination, Class # 01
TCM -T1017TL TARGETED CASE MANAGEMENT 7 7 6.872223 $254.2800 $37.0000
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Subtotal (Total Children Is Unduplicated) 7 7 6.872223 $254.2800 $37.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 71 72 70.571428 $836.9800 $11.8600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 69 70 68.571428 $567.7700 $8.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 69 70 68.571428 $711.7700 $10.3800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 69 70 68.571428 $1445.4900 $21.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 50 51 50.285714 $1367.2700 $27.1900
AUDE -AUDE UNSPECIFIED AUDE SERVICES 42 44 43.133333 $2588.0000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 2.133333 $96.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 6.000000 $690.0000 $115.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 17 18 6.816666 $340.8300 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 19 21 21.233334 $1029.8200 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 6 6 6.000000 $291.0000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 25 31 30.215068 $1465.4300 $48.5000
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Subtotal (Total Children Is Unduplicated) 165 460 442.103160 $11430.3500 $25.8500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 12 16 63.000000 $94500.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 5 6 11.261905 $563.1000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 65 77 75.964286 $3798.2200 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.500000 $12.5000 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 38 40 11.894444 $594.7200 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 49 51 23.777775 $1188.8800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 30 31 31.672221 $1583.6100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 90 97 45.405551 $2270.2600 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 10 11 73.200002 $1830.0100 $25.0000
EIIF -90801 PSYCHIATRIC DIAG INTERVIEW 1 1 4.400000 $220.0000 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 7.866667 $196.6700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 262 312 2064.766665 $103238.3300 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 11 11 67.033332 $3351.6600 $50.0000
INTR -INTR INTERPRETER 2 9 18.000000 $900.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 121 148 615.483339 $41779.0500 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 7 7 30.400000 $1651.3300 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 228 285 932.405557 $63291.7000 $67.8800
PHY -97110HM PT SESSION BY PT ASST 4 4 7.783333 $422.7900 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 65 68 68.000000 $68.0000 $1.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.000000 $1000.0000 $500.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 4.000000 $912.0000 $228.0000
SENS -V5264 EARMOLD 6 6 11.000000 $198.0000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 10 13 22.433333 $1121.6700 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 207 262 1145.134919 $77731.7400 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 4.933333 $267.9800 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 15.466667 $204.1600 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 2 2 201.333333 $100.6700 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 14 20 57.641666 $2882.0800 $50.0000
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Subtotal (Total Children Is Unduplicated) 662 1485 5616.758328 $405879.0800 $72.2600
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Total 1952 6065.733711 $417563.7000 $68.8400
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Number of Children (Unduplicated) With at Least One Authorization 695