Summary Report for FSPSAs Ending During the Report Period Center: 10
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
Service Coordination, Class # 01
SCONLY-SCONLY SERVICE COORDINATION ONLY 60 64 32.577778 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 60 64 32.577778 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 74 76 26.830153 $350.1300 $13.0500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 75 77 26.841264 $244.5200 $9.1100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 74 75 26.841264 $250.6900 $9.3400
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 74 76 26.852375 $583.4900 $21.7300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 64 66 24.763487 $605.9500 $24.4700
AUDE -AUDE UNSPECIFIED AUDE SERVICES 43 45 70.055561 $4203.3700 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 1.547641 $69.6500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 4.095282 $470.9600 $115.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 6 6 1.016666 $50.8300 $50.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 3 0.494445 $27.4400 $55.5100
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 31 31 58.522225 $2838.3400 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 7 7 2.588889 $125.5600 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 30 31 66.033334 $3202.6200 $48.5000
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Subtotal (Total Children Is Unduplicated) 173 500 336.482586 $13023.5500 $38.7000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 8 9 8.755555 $13133.2500 $1499.9900
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 20.923809 $1046.2000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 62 74 13.816669 $690.8500 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 4 4 1.013890 $25.3500 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 60 71 24.488891 $1224.4600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 46 53 24.205554 $1210.2700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 0.427778 $10.7000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 39 44 22.916666 $1145.8300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 129 144 60.811116 $3040.5800 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 9 11 53.238097 $1330.9600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 372 484 3000.692069 $150034.6300 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 1 2.800000 $140.0000 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 8 8 66.192857 $3309.6500 $50.0000
INTR -INTR INTERPRETER 2 4 0.116666 $5.8300 $49.9700
OCCT -97530 OT SESSION BY LICENSED OT 151 185 813.022219 $55187.9200 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 4 4 11.600000 $630.1100 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 235 273 906.994843 $61566.8200 $67.8800
PHY -97110HM PT SESSION BY PT ASST 5 5 17.100000 $928.8700 $54.3200
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.377778 $688.9000 $500.0100
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 1.717504 $391.5900 $228.0000
SENS -V5264 EARMOLD 3 3 3.095282 $55.7200 $18.0000
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 7 10 26.138888 $1306.9400 $50.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 6 6 7.794445 $389.7300 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 207 257 1071.280950 $72718.5300 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 1.800000 $23.7600 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 364 517 82284.749200 $41142.3700 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 3 3 12.685714 $634.2900 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 20 20 129.586111 $6479.3100 $50.0000
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Subtotal (Total Children Is Unduplicated) 691 2201 88589.342551 $418493.3800 $4.7200
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Total 2765 88958.402915 $431516.9300 $4.8500
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Number of Children (Unduplicated) With at Least One Authorization 823