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: 10-01-13 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 20 20 9.088889 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 20 20 9.088889 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 11 11 4.022223 $57.7600 $14.3600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 10 10 3.166667 $58.4600 $18.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 11 11 4.022223 $40.3000 $10.0200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 11 11 4.022223 $33.8300 $8.4100
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 10 10 3.166667 $24.5400 $7.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 10 10 3.922223 $82.3700 $21.0000
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 10 10 3.166667 $198.3300 $62.6300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 11 11 4.022223 $88.5700 $22.0200
AUDE -AUDE UNSPECIFIED AUDE SERVICES 43 43 209.800001 $12588.0100 $60.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 2.555555 $293.8800 $115.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 23 23 13.644446 $661.7600 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 2.233334 $108.3200 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 30 31 17.244446 $836.3600 $48.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 99 188 274.988898 $15072.4900 $54.8100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 6 15.433334 $77167.0000 $5000.0200
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 0.288889 $14.4500 $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 107 109 129.844444 $6492.2200 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 33 33 25.205555 $1260.2800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 47 50 36.077776 $1803.8800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 96 98 70.577778 $3528.8900 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 8.933333 $223.3300 $25.0000
EIIF -COUN UNSPECIFIED COUNSELING 1 1 1.466667 $73.3400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 388 475 3188.533327 $159426.6400 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 11 11 82.433333 $4121.6700 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 7 7 32.800000 $1640.0000 $50.0000
INTR -INTR INTERPRETER 2 2 6.422222 $321.1100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 115 122 604.366665 $41024.4000 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 164 174 768.105561 $52139.0400 $67.8800
SENS -V5264 EARMOLD 4 4 4.244445 $76.4000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 6 6 25.955556 $1297.7800 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 161 171 886.433329 $60171.0700 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 10.666667 $140.8000 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 1 1 7.866667 $786.6700 $100.0000
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 453 674 4043.815868 $40438.1500 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 7 8 23.655557 $11.8300 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 6 6 33.088889 $1654.4500 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 3.300000 $165.0000 $50.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 640 2075 10090.918245 $458036.0000 $45.3900
-------------------------------------------------------------------------------------------------------------------------------------
Total 2283 10374.996032 $473108.4900 $45.6000
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 678