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: 10-01-13 and 12-31-13 Date of Report: 02-18-14 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 34 35 16.333332 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 34 35 16.333332 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.688889 $9.8900 $14.3600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.688889 $12.7200 $18.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.688889 $6.9000 $10.0200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.688889 $5.7900 $8.4100
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 0.688889 $5.3400 $7.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.688889 $14.4700 $21.0000
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 0.688889 $43.1500 $62.6300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.688889 $15.1700 $22.0200
AUDE -AUDE UNSPECIFIED AUDE SERVICES 35 38 103.488892 $6209.3500 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.633333 $28.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 1.322222 $152.0500 $115.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 24 25 9.444442 $458.0400 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 0.688889 $33.4100 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 28 30 14.933333 $724.2700 $48.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 82 105 136.022223 $7719.0500 $56.7500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 10 12 21.377778 $106889.0000 $5000.0100
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 4.071429 $203.5700 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 87 109 80.902383 $4045.1300 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.500000 $12.5000 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 66 68 29.444446 $1472.2300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 53 57 34.311112 $1715.5600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 62 65 40.111108 $2005.5400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 121 126 61.405554 $3070.2700 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 5 5 22.933333 $573.3300 $25.0000
EIIF -COUN UNSPECIFIED COUNSELING 1 1 1.466667 $73.3400 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 1.466667 $73.3400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 436 511 3060.944452 $153047.2600 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 11 11 59.733333 $2986.6700 $50.0000
INTR -INTR INTERPRETER 3 3 22.355555 $1117.7800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 126 141 586.288890 $39797.3000 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 229 247 882.700003 $59917.7000 $67.8800
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 1.266667 $288.8100 $228.0100
SENS -V5264 EARMOLD 2 2 2.977778 $53.6000 $18.0000
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 1 0.300000 $15.0000 $50.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 5 5 15.077778 $753.8900 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 201 221 1000.400001 $67907.1600 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 2.533333 $33.4400 $13.2000
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 504 718 3948.393658 $39483.9400 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 24 25 256.433334 $128.2200 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 11 11 59.152579 $2957.6300 $50.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 755 2344 10196.547838 $488622.1800 $47.9200
-------------------------------------------------------------------------------------------------------------------------------------
Total 2484 10348.903393 $496341.2300 $47.9600
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 812