Summary Report for FSPSAs Ending During the Report Period Center: 06
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
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 3.000000 $135.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 3.000000 $345.0000 $115.0000
EXIT -EXIT TRANSITION ASSESSMENT 6 6 12.000000 $600.0000 $50.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 1 1 1.000000 $48.5000 $48.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 10 13 19.000000 $1128.5000 $59.3900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $1500.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 24 26 39.793650 $1989.6900 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 52 53 50.392857 $2519.6500 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 11 11 8.250000 $206.2500 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 5 5 8.283334 $414.1700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 16 16 25.885714 $1294.2900 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 6 6 7.233334 $361.6700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 5.500000 $137.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 16 16 25.133334 $1256.6700 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 12.000000 $300.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 132 138 861.414289 $43070.7200 $50.0000
INTR -INTR INTERPRETER 48 61 228.072620 $11403.6200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 34 39 138.528570 $9403.3100 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 63 69 214.002382 $14526.4800 $67.8800
SCONLY-SCONLY SERVICE COORDINATION ONLY 39 43 43.000000 $43.0000 $1.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 3 3.000000 $1500.0000 $500.0000
SENS -V5264 EARMOLD 5 5 1.788889 $32.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 87 98 396.842855 $26937.6900 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 6 7 88.571427 $1169.1400 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 1 1 1.000000 $100.0000 $100.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 4 4 53.142857 $26.5700 $0.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 359 604 2212.836112 $118192.6100 $53.4100
-------------------------------------------------------------------------------------------------------------------------------------
Total 617 2231.836112 $119321.1100 $53.4600
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 359