Summary Report for FSPSAs Initiated During the Report Period Center: 06
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: 10-01-11 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 2 2 2.000000 $90.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.000000 $230.0000 $115.0000
EXIT -EXIT TRANSITION ASSESSMENT 7 7 14.000000 $700.0000 $50.0000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.000000 $48.5000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 1 1 1.000000 $48.5000 $48.5000
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Subtotal (Total Children Is Unduplicated) 11 13 20.000000 $1117.0000 $55.8500
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 16 17 25.223808 $1261.1900 $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 11 11 16.538097 $826.9100 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 2.533333 $63.3300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 12 12 30.847619 $1542.3800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.300000 $32.5000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 12 12 18.835713 $941.7800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.700000 $42.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 19 20 32.049999 $1602.5000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 2.733333 $68.3300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 145 155 976.136510 $48806.8000 $50.0000
INTR -INTR INTERPRETER 46 58 235.986905 $11799.3500 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 50 56 217.714284 $14778.4300 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 2 2 3.928572 $213.4000 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 57 58 247.316666 $16787.8900 $67.8800
PHY -97110HM PT SESSION BY PT ASST 1 1 2.928571 $159.0800 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 25 25 25.000000 $25.0000 $1.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 2.000000 $1000.0000 $500.0000
SENS -V5264 EARMOLD 2 2 1.333334 $24.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 88 93 447.366671 $30367.2200 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 5 6 32.714286 $431.8300 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 1 1 1.000000 $100.0000 $100.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 197 257 91284.333323 $45642.1700 $0.5000
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Subtotal (Total Children Is Unduplicated) 323 857 93668.163881 $179242.4800 $1.9100
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Total 870 93688.163881 $180359.4800 $1.9300
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Number of Children (Unduplicated) With at Least One Authorization 329