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
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Subtotal (Total Children Is Unduplicated) 3 3 1.511112 $55.9100 $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 4 4 1.449999 $86.9900 $60.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.126027 $14.4900 $114.9800
EXIT -EXIT TRANSITION ASSESSMENT 28 28 24.049208 $1202.4700 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 0.144444 $10.8300 $74.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 0.144444 $8.0100 $55.4800
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Subtotal (Total Children Is Unduplicated) 36 37 28.914122 $1468.2900 $50.7800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 1.359360 $2038.9500 $1499.9300
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
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 8 8 34.529366 $1726.4700 $50.0000
PHY -97110 PT SESSION BY LICENSED PT 1 1 10.714286 $727.2900 $67.8800
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
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 261 681 115700.166665 $57850.0800 $0.5000
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Subtotal (Total Children Is Unduplicated) 275 1224 116493.532781 $109896.4500 $0.9400
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Total 1264 116523.958015 $111420.6600 $0.9600
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Number of Children (Unduplicated) With at Least One Authorization 276