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: 10-01-12 and 12-31-12 Date of Report: 02-16-13 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 1 1 1.400000 $23.4900 $16.7800
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.400000 $12.7500 $9.1100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.400000 $13.0800 $9.3400
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.400000 $30.4200 $21.7300
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Subtotal (Total Children Is Unduplicated) 1 4 5.600000 $79.7400 $14.2400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.322222 $483.3000 $1499.9000
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 1.400000 $70.0000 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 513 573 820.893654 $41044.7100 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 517 562 860.152385 $43007.6500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 512 561 814.331749 $40716.6100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 513 573 823.170637 $41158.5500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 335 377 2014.446016 $100722.3600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 73 82 306.910311 $20833.0900 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 141 155 766.494040 $52029.6700 $67.8800
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 13 14 10.232541 $511.6300 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 234 274 1186.927777 $80568.6800 $67.8800
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Subtotal (Total Children Is Unduplicated) 606 3173 7605.281332 $421146.2300 $55.3800
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Total 3177 7610.881332 $421225.9700 $55.3500
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Number of Children (Unduplicated) With at Least One Authorization 606