Summary Report for FSPSAs Ending During the Report Period Center: 01
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: 10-01-11 and 12-31-11 Date of Report: 02-15-12 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
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 8 8 10.000000 $485.0000 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 7 7 6.066667 $364.0000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.000000 $90.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 4.122223 $474.0600 $115.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 2 2 4.000000 $500.0000 $125.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 17 19 38.000000 $4750.0000 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 107 110 219.250000 $10962.5000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 13 13 26.000000 $1950.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 15 16 32.000000 $2400.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 14 14 28.000000 $1554.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 135 135 270.500000 $20287.5000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 58 58 116.000000 $8700.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 135 135 270.000000 $14985.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 171 187 374.500000 $28087.5000 $75.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 1.000000 $48.5000 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 2.000000 $97.0000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 5 5 5.000000 $242.5000 $48.5000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.000000 $15.0000 $15.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 14 14 25.714286 $1247.1400 $48.5000
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Subtotal (Total Children Is Unduplicated) 423 736 1439.153176 $97539.7100 $67.7800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 9 9 11.000000 $16500.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 10 10 11.323810 $566.1900 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 99 109 172.978571 $8648.9400 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 6 6 3.000000 $75.0000 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 30 32 66.752379 $3337.6200 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 8 8 13.566666 $339.1700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 6 6 11.000000 $550.0000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 23 24 36.476189 $1823.8100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 9 9 10.700000 $267.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 26 27 58.866666 $2943.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 7 7 21.023809 $525.5900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 11 11 83.285714 $2082.1400 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 4 4 17.380952 $869.0500 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 3 3 15.000000 $375.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 434 463 2620.214305 $131010.6400 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 12.857143 $642.8600 $50.0000
INTR -INTR INTERPRETER 65 102 184.273812 $9213.6800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 8 9 60.857144 $4130.9800 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 69 71 384.919051 $26128.3200 $67.8800
PHY -97110HM PT SESSION BY PT ASST 3 4 31.285714 $1699.4400 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 53 53 62.960317 $62.9600 $1.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 3 4.000000 $2000.0000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 3.000000 $195.0000 $65.0000
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 1.000000 $114.0000 $114.0000
SENS -V5264 EARMOLD 2 2 4.055556 $73.0000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 5 5 14.500000 $725.0000 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 101 107 655.038100 $44463.9500 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 28.428571 $375.2600 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 665 894 4135.104788 $2067.5600 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 31.000001 $1550.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 751 1989 8765.849258 $263355.9600 $30.0400
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Total 2725 10205.002434 $360895.6700 $35.3600
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Number of Children (Unduplicated) With at Least One Authorization 925