Summary Report for FSPSAs Initiated During the Report Period Center: 53
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
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 4 4 4.000000 $194.0000 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 22 22 21.577777 $1294.6600 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 7 7 8.500000 $382.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 21 21 23.777778 $2734.4500 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 9 9 18.428571 $2303.5800 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 11 11 18.000000 $900.0000 $50.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 8 8 11.000000 $610.5000 $55.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 3 3 3.000000 $145.5000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 5 5 5.000000 $242.5000 $48.5000
SCREEN-T1023 INTERDISCIPLINARY SCREENING 1 1 1.000000 $50.0000 $50.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 8 8 8.000000 $388.0000 $48.5000
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Subtotal (Total Children Is Unduplicated) 77 99 122.284126 $9245.6800 $75.6100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 12 13 21.000000 $31500.0000 $1500.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.000000 $68.8600 $68.8600
AUD -HA_FUP AUDIOLOGY SERVICES 9 9 40.171430 $2008.5700 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 2 2.000000 $100.0000 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 25 31 52.509523 $2625.4700 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 9 11 9.500000 $237.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 12 13 14.766667 $738.3400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 37 38 42.566667 $2128.3400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 3 3 2.000000 $50.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 26 27 35.966667 $1798.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 3.000000 $75.0000 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 7 7 19.504762 $1430.0800 $73.3200
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 1.571429 $39.2900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 12 12 30.347619 $758.6900 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 13.428571 $671.4300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 184 211 1085.576186 $54278.8200 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 6 7 16.538096 $826.9100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 10 10 53.071429 $3602.4900 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 2 2 13.571429 $737.2000 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 15 15 99.447620 $6750.5100 $67.8800
PHY -97110HM PT SESSION BY PT ASST 3 3 16.285715 $884.6400 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 12 12 8.422221 $8.4200 $1.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.043836 $2.8500 $64.9500
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.000000 $456.0000 $228.0000
SENS -V5264 EARMOLD 6 6 8.500000 $153.0000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 10 10 10.666666 $533.3300 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 19 19 125.790477 $8538.6700 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 47.285715 $624.1700 $13.2000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 11.857143 $592.8600 $50.0000
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Subtotal (Total Children Is Unduplicated) 242 476 1788.389868 $122219.7400 $68.3400
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Total 575 1910.673994 $131465.4300 $68.8100
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Number of Children (Unduplicated) With at Least One Authorization 253