Summary Report for FSPSAs Ending During the Report Period Center: 52
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 2 2 1.833333 $110.0000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.0000 $45.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 1.000000 $125.0000 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 3 3 3.000000 $150.0000 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 26 32 32.000000 $1552.0000 $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 17 19 19.000000 $921.5000 $48.5000
SCREEN-T1023 INTERDISCIPLINARY SCREENING 18 20 20.000000 $1000.0000 $50.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 50 59 59.000000 $2861.5000 $48.5000
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Subtotal (Total Children Is Unduplicated) 96 138 137.833333 $6813.5000 $49.4300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 4 4.000000 $6000.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 1.000000 $50.0000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 2.900000 $145.0000 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 73 81 107.938095 $5396.9000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 41 44 59.833333 $2991.6700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 35 37 54.666667 $2733.3400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 76 85 121.052379 $6052.6100 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 4 4 13.714285 $342.8600 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 5 5.000000 $250.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 88 104 322.073810 $16103.7000 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 4 5 49.428571 $2471.4300 $50.0000
INTR -INTR INTERPRETER 9 9 24.366667 $1218.3400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 34 36 192.849998 $13090.6600 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 49 55 266.058331 $18060.0400 $67.8800
PHY -97110HM PT SESSION BY PT ASST 2 3 4.857143 $263.8400 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 7 7 4.188889 $4.1900 $1.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.000000 $1000.0000 $500.0000
SENS -V5264 EARMOLD 1 1 1.666667 $30.0000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 4 4 17.142857 $857.1500 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 113 122 438.241660 $29747.9100 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 12.428571 $164.0600 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 169 261 85963.309518 $42981.6600 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 1 1 0.383333 $19.1700 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 4 13.928572 $696.4300 $50.0000
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Subtotal (Total Children Is Unduplicated) 212 876 87683.029346 $150670.9200 $1.7200
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Total 1014 87820.862679 $157484.4200 $1.7900
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Number of Children (Unduplicated) With at Least One Authorization 240