Summary Report for FSPSAs Initiated During the Report Period Center: 53
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: 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 6 6 6.000000 $291.0000 $48.5000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.000000 $230.0000 $115.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 1 1 1.000000 $50.0000 $50.0000
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 3 3 3.000000 $150.0000 $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 2 2 2.000000 $97.0000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 3 3 3.000000 $145.5000 $48.5000
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Subtotal (Total Children Is Unduplicated) 17 18 18.000000 $1012.0000 $56.2200
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 7 7 22.661905 $1133.1000 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 27 28 39.176191 $1958.8200 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 3 3 3.000000 $75.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 6 6 5.800000 $290.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.000000 $25.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 35 38 49.161905 $2458.1000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 3 3 3.000000 $75.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 33 35 41.838812 $2091.9400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 5 6.833333 $170.8300 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 0.811111 $59.4700 $73.3200
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 4.285714 $107.1400 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 10.000000 $250.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 12 15 62.871429 $3143.5800 $50.0000
INTR -INTR INTERPRETER 1 1 1.000000 $50.0000 $50.0000
PHY -97110 PT SESSION BY LICENSED PT 1 1 0.714286 $48.4900 $67.8800
SCONLY-SCONLY SERVICE COORDINATION ONLY 11 11 7.804763 $7.8000 $1.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 4 4.117808 $267.6600 $65.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 6.428571 $436.3700 $67.8800
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Subtotal (Total Children Is Unduplicated) 117 162 270.505828 $12648.2900 $46.7600
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Total 181 288.755828 $13669.5400 $47.3400
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Number of Children (Unduplicated) With at Least One Authorization 125