Summary Report for FSPSAs Ending During the Report Period Center: 57
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 -92585 AUD EVOKED RESPONSE (DIAG) 6 6 6.000000 $310.5600 $51.7600
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 4.000000 $460.0000 $115.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 48 49 49.000000 $2376.5000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 63 64 66.315080 $3216.2900 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 104 107 117.286509 $5688.4000 $48.5000
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Subtotal (Total Children Is Unduplicated) 163 231 243.601589 $12096.7500 $49.6600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 6.142857 $9214.3500 $1500.0100
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1 1 0.261111 $13.0600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 7 7 13.406350 $670.3200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 16 17 14.283334 $714.1700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 169 175 74.858733 $3742.9400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 0.744444 $18.6100 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 37 37 243.000004 $6075.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 249 265 1781.357163 $89067.8400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 70 71 367.142860 $24921.6400 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 86 88 339.464287 $23042.8200 $67.8800
SCONLY-SCONLY SERVICE COORDINATION ONLY 9 9 8.211111 $8.2100 $1.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 3 12.334921 $616.7500 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 128 132 485.964291 $32987.2000 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 7.285714 $96.1700 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 272 312 3579.949226 $1789.9800 $0.5000
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Subtotal (Total Children Is Unduplicated) 358 1125 6934.406406 $192979.0400 $27.8300
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Total 1356 7178.007995 $205075.7900 $28.5700
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Number of Children (Unduplicated) With at Least One Authorization 360