Summary Report for FSPSAs Ending During the Report Period Center: 53
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: 07-01-11 and 09-30-11 Date of Report: 11-30-11 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
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 0.250000 $9.2500 $37.0000
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Subtotal (Total Children Is Unduplicated) 1 1 0.250000 $9.2500 $37.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 5 5 5.000000 $242.5000 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.000000 $60.0000 $60.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 3.000000 $345.0000 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 2 2 2.000000 $250.0000 $125.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 3.000000 $166.5000 $55.5000
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 3 3 3.900000 $195.0000 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 1.000000 $48.5000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.000000 $48.5000 $48.5000
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Subtotal (Total Children Is Unduplicated) 18 18 19.900000 $1356.0000 $68.1400
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 6 6 9.585714 $479.2900 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 21 22 26.000000 $1300.0000 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 3 3 4.966667 $124.1700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 3.533333 $176.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.000000 $25.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 20 21 21.700000 $1085.0000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.000000 $25.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 27 29 37.399999 $1870.0000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 2.107143 $52.6800 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 2 2 2.066667 $151.5300 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 6 6 25.295239 $632.3800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 17 20 73.871428 $3693.5800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 16.571428 $1124.8700 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 2 2 3.233334 $219.4800 $67.8800
SCONLY-SCONLY SERVICE COORDINATION ONLY 12 12 8.011110 $8.0100 $1.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.000000 $65.0000 $65.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 3.066667 $153.3400 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 2 23.285714 $1580.6300 $67.8800
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 10.285714 $514.2900 $50.0000
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Subtotal (Total Children Is Unduplicated) 95 137 273.980157 $13280.9000 $48.4700
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Total 156 294.130157 $14646.1500 $49.7900
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Number of Children (Unduplicated) With at Least One Authorization 107