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 26 27 10.188887 $132.9600 $13.0500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 26 27 10.188887 $92.8200 $9.1100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 26 27 10.188887 $95.1600 $9.3400
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 26 27 10.188887 $221.4000 $21.7300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 21 22 9.144443 $223.7600 $24.4700
AUDE -AUDE UNSPECIFIED AUDE SERVICES 15 16 43.466669 $2608.0100 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.688889 $31.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.377778 $273.4500 $115.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 8 8 5.444446 $264.0600 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 0.544445 $26.4100 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 6 6 12.877778 $624.5700 $48.5000
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Subtotal (Total Children Is Unduplicated) 52 166 115.299996 $4593.6100 $39.8400
EI Services, Class # 03
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 59 79 583.431747 $29171.6000 $50.0000
INTR -INTR INTERPRETER 2 4 0.116666 $5.8300 $49.9700
OCCT -97530 OT SESSION BY LICENSED OT 30 39 149.349999 $10137.8700 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.066667 $57.9400 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 45 54 169.658334 $11516.4100 $67.8800
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.377778 $688.9000 $500.0100
SENS -V5264 EARMOLD 1 1 1.377778 $24.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 58 77 316.566666 $21488.5400 $67.8800
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 364 517 82284.749200 $41142.3700 $0.5000
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Subtotal (Total Children Is Unduplicated) 471 1181 83729.537305 $123959.4400 $1.4800
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Total 1411 83877.415079 $128553.0500 $1.5300
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Number of Children (Unduplicated) With at Least One Authorization 556