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: 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 7 7 7.000000 $339.5000 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 27 30 32.922223 $1975.3400 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 4.000000 $180.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 18 18 22.044444 $2535.1100 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 3 3 3.000000 $375.0000 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 26 27 48.500000 $2425.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 2 2.000000 $150.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 15 15 30.000000 $2250.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 17 17 33.000000 $1831.5000 $55.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 3 3 11.142857 $540.4300 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 2 2 2.000000 $97.0000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 1 1 1.000000 $48.5000 $48.5000
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Subtotal (Total Children Is Unduplicated) 96 129 196.609524 $12747.3700 $64.8400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 7 9.000000 $13500.0000 $1500.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 3 3 4.000000 $275.4400 $68.8600
AUD -HA_FUP AUDIOLOGY SERVICES 10 10 54.204761 $2710.2400 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 16 18 32.817460 $1640.8800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 27 28 52.652383 $2632.6300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 36 41 73.557144 $3677.8700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 32 35 63.185716 $3159.3100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 4.466667 $111.6700 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 9 10 30.171429 $2212.1700 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 6 7 19.280953 $482.0300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 192 235 1181.111099 $59055.5700 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 10 10 26.095238 $1304.7600 $50.0000
INTR -INTR INTERPRETER 2 2 4.377778 $218.8900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 7 7 25.500001 $1730.9500 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 1 1 4.428571 $240.5600 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 8 10 57.419047 $3897.6000 $67.8800
PHY -97110HM PT SESSION BY PT ASST 8 8 58.142857 $3158.3200 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 10 10 8.633332 $8.6300 $1.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 4 4.000000 $260.0000 $65.0000
SENS -V5264 EARMOLD 6 6 7.133334 $128.4000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 7 7 16.438095 $821.9000 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 14 14 57.261905 $3886.9500 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 28.571428 $377.1400 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 209 421 75409.503174 $37704.7500 $0.5000
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Subtotal (Total Children Is Unduplicated) 243 900 77231.952372 $143196.6300 $1.8500
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Total 1031 77429.561896 $155981.0100 $2.0100
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Number of Children (Unduplicated) With at Least One Authorization 246