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: 04-01-12 and 06-30-12 Date of Report: 08-16-12 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
TCM -T1017TL TARGETED CASE MANAGEMENT 1 2 1.000000 $37.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 1 2 1.000000 $37.0000 $37.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 5 5 5.000000 $242.5000 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 23 24 24.811111 $1488.6700 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 3.600000 $162.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 15 15 14.977778 $1722.4500 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 5 5 7.285715 $910.7100 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 12 12 17.000000 $850.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 9 9 16.000000 $1200.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 12 13 21.000000 $1165.5000 $55.5000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 1.000000 $50.0000 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 1.000000 $48.5000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 7 7 7.000000 $339.5000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 3 3 3.000000 $145.5000 $48.5000
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Subtotal (Total Children Is Unduplicated) 75 99 121.674604 $8325.3300 $68.4200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 14 15 19.000000 $28500.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 7 7 18.666666 $933.3300 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 1.000000 $50.0000 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 21 24 37.285714 $1864.2900 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 4 4 5.266667 $131.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 15 16 28.100000 $1405.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.133333 $28.3300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 46 50 65.800795 $3290.0400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 6 6 5.800000 $145.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 31 32 69.666668 $3483.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.000000 $25.0000 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 5 5 17.923809 $1314.1800 $73.3200
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 11.571429 $289.2900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 19 19 73.061906 $1826.5500 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 211 248 1128.395237 $56419.7500 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 5 5 10.233332 $511.6600 $50.0000
INTR -INTR INTERPRETER 1 1 2.666667 $133.3400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 10 10 50.414285 $3422.1100 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 18 21 124.133331 $8426.1800 $67.8800
PHY -97110HM PT SESSION BY PT ASST 1 1 2.933333 $159.3400 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 10 10 5.033334 $5.0300 $1.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.208219 $13.5300 $64.9900
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.000000 $456.0000 $228.0000
SENS -V5264 EARMOLD 5 5 7.699999 $138.6000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 7 7 12.566666 $628.3300 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 12 13 60.971427 $4138.7300 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 15.428572 $203.6600 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 93 159 28934.942859 $14467.4700 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 3.285714 $164.2900 $50.0000
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Subtotal (Total Children Is Unduplicated) 261 669 30716.189962 $132574.0300 $4.3200
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Total 770 30838.864566 $140936.3500 $4.5700
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Number of Children (Unduplicated) With at Least One Authorization 273