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: 07-01-12 and 09-30-12 Date of Report: 11-15-12 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 0.177778 $6.5800 $37.0000
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Subtotal (Total Children Is Unduplicated) 1 1 0.177778 $6.5800 $37.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 2 2.000000 $97.0000 $48.5000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.0000 $115.0000
EXIT -EXIT TRANSITION ASSESSMENT 24 26 39.255557 $1962.7900 $50.0000
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Subtotal (Total Children Is Unduplicated) 27 29 42.255557 $2174.7900 $51.4700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 3.000000 $4500.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 6 6 12.231746 $611.5900 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 14 16 2.128770 $106.4400 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.644444 $16.1100 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 36 96 179.354761 $8967.7100 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 2.500000 $62.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 35 36 63.723807 $3186.1900 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 42 46 78.857144 $3942.8600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 40 41 73.426982 $3671.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 7 8 10.011111 $250.2800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 6 6 25.119049 $1255.9600 $50.0000
INTR -INTR INTERPRETER 2 2 5.266667 $263.3400 $50.0000
SCONLY-SCONLY SERVICE COORDINATION ONLY 10 11 5.666668 $5.6700 $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
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 10.714286 $141.4300 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 229 495 90717.130155 $45358.5700 $0.5000
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Subtotal (Total Children Is Unduplicated) 256 773 91195.775590 $73599.9500 $0.8100
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Total 803 91238.208925 $75781.3200 $0.8300
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Number of Children (Unduplicated) With at Least One Authorization 256