Summary Report for FSPSAs Ending During the Report Period Center: 01
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: 10-01-12 and 12-31-12 Date of Report: 02-16-13 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
SCONLY-SCONLY SERVICE COORDINATION ONLY 21 21 755.422223 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 21 21 755.422223 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 8 8 5.088888 $246.8100 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 4 4 5.918797 $355.1300 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 0.705556 $31.7500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 6 6 7.639681 $878.5500 $115.0000
EXIT -EXIT EXIT ASSESSMENT 2 2 2.466667 $123.3400 $50.0000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 4 4 2.450000 $118.8300 $48.5000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.250000 $3.7500 $15.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 1 1 0.027778 $1.3500 $48.5400
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Subtotal (Total Children Is Unduplicated) 23 28 24.547367 $1759.5000 $71.6800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 8 8 9.555556 $14333.4000 $1500.0100
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 6.303967 $315.2000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 6 7 7.600000 $380.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 2 4.066666 $101.6700 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 217 339 647.753167 $32387.6200 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 4.966667 $124.1700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 146 148 286.446826 $14322.3400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 5.366666 $134.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 170 171 276.815076 $13840.7300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 3 3 5.733333 $143.3300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 202 205 354.224600 $17711.2100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 8 8 17.266667 $431.6700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 11 11 61.285715 $1532.1400 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 16.695238 $834.7700 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 3 3 24.142856 $1207.1500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 397 399 2200.520657 $110025.9500 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 13.571429 $678.5700 $50.0000
INTR -INTR INTERPRETER 26 27 175.380953 $8769.0500 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 3.428571 $232.7300 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 1 1 3.285714 $178.4800 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 39 39 204.642859 $13891.1300 $67.8800
PHY -97110HM PT SESSION BY PT ASST 3 3 19.428572 $1055.3600 $54.3200
SENS -FM FM RECEIVER HEARING AID 1 1 1.766667 $2915.0600 $1650.0300
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 1.161111 $580.5500 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.500000 $97.5000 $65.0000
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 0.250000 $28.5000 $114.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 1.133333 $258.3900 $227.9900
SENS -V5264 EARMOLD 6 6 5.608522 $100.9500 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 13.428572 $671.4300 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 43 43 340.571432 $23117.9800 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 5.571429 $302.6400 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 23.285715 $307.3700 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 459 539 3052.481769 $1526.2400 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 9.428571 $471.4300 $50.0000
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Subtotal (Total Children Is Unduplicated) 479 1989 7804.668876 $263008.8600 $33.7000
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Total 2038 8584.638466 $264768.3500 $30.8400
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Number of Children (Unduplicated) With at Least One Authorization 504