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: 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 3 3 1.511112 $55.9100 $37.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 2.000000 $74.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 4 4 3.511112 $129.9100 $37.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 2 3.000000 $145.5000 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 36 37 26.216667 $1573.0000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 5 5 4.172223 $187.7500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 7 7 6.284757 $722.7400 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.000000 $125.0000 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 28 28 24.049208 $1202.4700 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 0.600000 $45.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 8 8 9.944444 $745.8300 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 0.011111 $0.8300 $74.9300
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 11 11 10.766666 $597.5500 $55.5000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 3 3 0.033333 $1.8500 $55.4400
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 3 3 0.033333 $2.5000 $74.9300
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 1.000000 $48.5000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 5 5 3.627778 $175.9500 $48.5000
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Subtotal (Total Children Is Unduplicated) 82 113 90.739520 $5574.4600 $61.4300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 6 9.332375 $13998.4500 $1499.9900
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.105556 $7.2700 $68.8900
AUD -HA_FUP AUDIOLOGY SERVICES 8 8 41.744444 $2087.2200 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 16 19 3.745438 $187.2800 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 84 367 501.045844 $25052.3100 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 5 5 1.930555 $48.2600 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 28 31 56.529363 $2826.4700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 28 31 54.427777 $2721.3900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 3 3 2.866667 $71.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 46 47 65.968250 $3298.3900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 5 3.600000 $90.0000 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 7 8 15.866668 $1163.3500 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 15 15 38.104759 $952.6200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 214 258 1158.578578 $57928.9500 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 12.926985 $646.3500 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 7 8 61.209525 $4154.9000 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 1 1 6.714286 $364.7200 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 12 13 73.142859 $4964.9400 $67.8800
PHY -97110HM PT SESSION BY PT ASST 6 7 43.714286 $2374.5600 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 11 11 5.077781 $5.0800 $1.0000
SENS -FM FM RECEIVER HEARING AID 1 1 6.571429 $10842.8100 $1649.9900
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 0.255556 $127.8000 $500.0900
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 3.000000 $195.0000 $65.0000
SENS -V5264 EARMOLD 4 4 6.066666 $109.2000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 8 9 52.666667 $2633.3400 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 8 8 20.942858 $1421.6000 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 9.171429 $121.0600 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 261 682 115800.166665 $57900.0800 $0.5000
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Subtotal (Total Children Is Unduplicated) 283 1555 118055.473266 $196295.0500 $1.6600
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Total 1672 118149.723898 $201999.4300 $1.7100
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Number of Children (Unduplicated) With at Least One Authorization 285