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: 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
Service Coordination, Class # 01
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 0.044444 $1.6400 $36.9600
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Subtotal (Total Children Is Unduplicated) 1 1 0.044444 $1.6400 $36.9600
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 4 4 4.000000 $194.0000 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 33 34 42.536508 $2552.1900 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.000000 $90.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 14 14 19.000000 $2185.0000 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.000000 $125.0000 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 14 14 18.000000 $900.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 3 4 5.000000 $375.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 14 14 25.000000 $1875.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 19 19 34.000000 $1887.0000 $55.5000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 1.000000 $50.0000 $50.0000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 8 8 8.000000 $388.0000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 6 6 6.000000 $291.0000 $48.5000
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Subtotal (Total Children Is Unduplicated) 88 121 165.536508 $10912.1900 $65.9200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 10 10 12.000000 $18000.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 36.173015 $1808.6500 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 0.500000 $25.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.377778 $9.4500 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 29 33 54.266666 $2713.3300 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 4.900000 $122.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 19 21 35.866666 $1793.3300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 4 2.555556 $63.8900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 36 39 41.735715 $2086.7900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 4 5 4.900000 $122.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 37 45 63.438095 $3171.9000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 7 7 3.544444 $88.6100 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 6 6 17.871430 $1310.3400 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 16 16 34.104761 $852.6200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 232 268 1320.838096 $66041.9100 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 4 4 2.500000 $125.0000 $50.0000
INTR -INTR INTERPRETER 1 1 2.755556 $137.7800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 9 9 44.523811 $3022.2600 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 16 18 105.371429 $7152.6100 $67.8800
PHY -97110HM PT SESSION BY PT ASST 5 5 29.980953 $1628.5700 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 9 9 6.422221 $6.4200 $1.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.000000 $1000.0000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 4.000000 $260.0000 $65.0000
SENS -V5264 EARMOLD 2 2 4.400000 $79.2000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 5 5 3.400000 $170.0000 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 15 15 66.780955 $4533.1000 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 23.714286 $313.0300 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 146 261 33027.431737 $16513.7200 $0.5000
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Subtotal (Total Children Is Unduplicated) 278 799 34956.353170 $133152.5000 $3.8100
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Total 921 35121.934122 $144066.3300 $4.1000
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Number of Children (Unduplicated) With at Least One Authorization 279