Summary Report for FSPSAs Ending During the Report Period Center: 53
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 3 3 3.000000 $145.5000 $48.5000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.0000 $115.0000
EXIT -EXIT TRANSITION ASSESSMENT 8 8 15.000000 $750.0000 $50.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 2 2 2.000000 $100.0000 $50.0000
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 1 1 1.000000 $50.0000 $50.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 3 3 3.000000 $145.5000 $48.5000
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Subtotal (Total Children Is Unduplicated) 16 18 25.000000 $1306.0000 $52.2400
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 8 8 32.980953 $1649.0500 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 1.000000 $50.0000 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 22 22 36.761905 $1838.0900 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 5 5 6.651190 $166.2800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 10 10 13.800000 $690.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.000000 $25.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 28 29 37.047619 $1852.3800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 6 6 6.000000 $150.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 22 23 27.333334 $1366.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 8 8 15.666666 $391.6700 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 8.857143 $221.4300 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 0.800000 $20.0000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 12.857143 $642.8600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 9 11 33.719047 $1685.9400 $50.0000
INTR -INTR INTERPRETER 1 1 1.000000 $50.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 3.000000 $203.6400 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 1 1 9.714286 $659.4100 $67.8800
SCONLY-SCONLY SERVICE COORDINATION ONLY 12 12 6.255555 $6.2600 $1.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 2.208219 $143.5300 $65.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 0.133333 $6.6700 $49.9900
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 2 3.419047 $232.0800 $67.8800
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Subtotal (Total Children Is Unduplicated) 110 148 260.205440 $12050.9300 $46.3100
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Total 166 285.205440 $13356.9300 $46.8300
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Number of Children (Unduplicated) With at Least One Authorization 117