Summary Report for FSPSAs Initiated During the Report Period Center: 55
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 -AUDE UNSPECIFIED AUDE SERVICES 1 1 2.733333 $164.0000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 3.000000 $135.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.000000 $230.0000 $115.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 10 10 13.571429 $658.2100 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 22 23 23.000000 $1115.5000 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 5 6 6.000000 $291.0000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 7 7 7.000000 $339.5000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 35 36 34.616666 $1678.9100 $48.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 62 87 91.921428 $4612.1200 $50.1700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.000000 $4500.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 5.711111 $285.5600 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 3 3.000000 $150.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 2 2 2.400000 $60.0000 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 11 11 6.788889 $339.4500 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 12 12 18.866666 $471.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 6 6 7.505555 $375.2800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 4 4 5.866666 $146.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 1.416667 $70.8400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 3.133333 $78.3300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 11 11 9.394444 $469.7200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 10 10 16.433333 $410.8300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 34 34 258.000000 $12899.9900 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 13.571429 $678.5700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 48 49 297.959523 $20225.5300 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 2 2 14.571428 $791.5200 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 22 23 112.500000 $7636.5000 $67.8800
PHY -97110HM PT SESSION BY PT ASST 7 7 28.714285 $1559.7700 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 12 13 13.294445 $13.2900 $1.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.000000 $456.0000 $228.0000
SENS -V5264 EARMOLD 2 2 2.511111 $45.2000 $18.0000
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 1 10.285714 $514.2900 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 97 99 611.133328 $41483.7700 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 5.142857 $67.8900 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 150 177 1548.907142 $774.4500 $0.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 187 480 3002.107926 $94505.0800 $31.4800
-------------------------------------------------------------------------------------------------------------------------------------
Total 567 3094.029354 $99117.2000 $32.0300
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 190