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: 01-01-12 and 03-31-12 Date of Report: 05-15-12 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 39 39 39.200000 $2352.0000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 7 7 7.000000 $315.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 17 17 18.888889 $2172.2200 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 8 8 8.000000 $1000.0000 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 8 8 10.000000 $500.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 3.000000 $225.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 3 3 3.000000 $225.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 15 16 32.571429 $1807.7100 $55.5000
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 4 4 4.000000 $200.0000 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 2 2 2.000000 $97.0000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 4 4 4.000000 $194.0000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 26 27 27.000000 $1309.5000 $48.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 105 141 162.660318 $10591.4400 $65.1100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 7 7 13.000000 $19500.0000 $1500.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.000000 $68.8600 $68.8600
AUD -HA_FUP AUDIOLOGY SERVICES 8 9 20.323810 $1016.1900 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 2 1.500000 $75.0000 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 30 37 68.002379 $3400.1200 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 9 11 9.500000 $237.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 12 12 18.766667 $938.3400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 3 2.288889 $57.2200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 39 40 46.600001 $2330.0100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 2.000000 $50.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 49 52 58.172799 $2908.6400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 6 6 5.500000 $137.5000 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 6 7 8.603175 $630.7900 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 24 25 89.590475 $2239.7600 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 28.428571 $1421.4300 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 3.000000 $75.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 221 275 1365.342866 $68267.1600 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 6 6 23.842857 $1192.1500 $50.0000
INTR -INTR INTERPRETER 1 1 1.000000 $50.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 9 9 45.928571 $3117.6400 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 2 2 7.000000 $380.2400 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 21 24 170.571428 $11578.3900 $67.8800
PHY -97110HM PT SESSION BY PT ASST 9 9 52.571427 $2855.6800 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 10 10 10.515873 $10.5200 $1.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 2.000000 $130.0000 $65.0000
SENS -V5264 EARMOLD 6 6 6.111111 $110.0000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 9 10 15.231745 $761.5900 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 30 32 199.500000 $13542.0700 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 8 8 54.857142 $724.1200 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 28 34 2429.657142 $1214.8300 $0.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 283 645 4760.406928 $139020.7100 $29.2000
-------------------------------------------------------------------------------------------------------------------------------------
Total 786 4923.067246 $149612.1500 $30.3900
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 296