Summary Report for FSPSAs Ending During the Report Period Center: 07
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 -AUDE UNSPECIFIED AUDE SERVICES 6 6 6.000000 $360.0000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.233333 $256.8300 $115.0000
EXIT -EXIT TRANSITION ASSESSMENT 1 1 2.000000 $100.0000 $50.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 4.000000 $222.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 6 6 12.000000 $666.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 31 41 85.000000 $6375.0000 $75.0000
MED -MED UNSPECIFIED MED OFFICE VISIT 1 1 1.000000 $150.0000 $150.0000
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 1 1 1.000000 $50.0000 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 2 2 2.000000 $97.0000 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.000000 $48.5000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 3.000000 $145.5000 $48.5000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.000000 $15.0000 $15.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 10 10 19.515079 $946.4800 $48.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 59 79 144.748412 $9777.3100 $67.5500
EI Services, Class # 03
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.488889 $33.6700 $68.8600
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 4.000000 $200.0000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 5 4.666667 $233.3400 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 63 69 76.733333 $3836.6700 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 7 8 8.000000 $200.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 20 20 24.385714 $1219.2900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 2.000000 $50.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 19 20 27.142857 $1357.1400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 38 39 45.471428 $2273.5700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 10 10 10.600000 $265.0000 $25.0000
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 8.857143 $110.7100 $12.5000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 5 5 71.000000 $1775.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 288 313 1870.847622 $93542.3800 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 3 3 23.857143 $1192.8600 $50.0000
INTR -INTR INTERPRETER 2 2 4.000000 $200.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 15 17 113.428572 $7699.5300 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 2 3 21.071428 $1144.6000 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 22 22 114.857144 $7796.5100 $67.8800
PHY -97110HM PT SESSION BY PT ASST 1 1 0.857143 $46.5600 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 48 50 48.311112 $48.3100 $1.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.000000 $456.0000 $228.0000
SENS -V5264 EARMOLD 3 3 4.488889 $80.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 38 39 189.000001 $12829.3300 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 7 7 40.428572 $533.6500 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 11 13 67.999999 $34.0000 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 2.214286 $110.7200 $50.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 400 659 2787.707942 $137294.6200 $49.2500
-------------------------------------------------------------------------------------------------------------------------------------
Total 738 2932.456354 $147071.9300 $50.1500
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 433