Summary Report for FSPSAs Ending During the Report Period Center: 03
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 41 41 93.644445 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 41 41 93.644445 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 33 35 7.744446 $375.6100 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 16 16 3.305556 $198.3400 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.405556 $18.2500 $45.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 0.022222 $1.6700 $74.9300
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 0.011111 $0.8300 $74.9300
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 42 42 0.416659 $31.1900 $74.8600
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 12 12 0.111110 $8.3300 $74.9300
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 9 9 2.066667 $100.2400 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 10 10 1.955554 $94.8400 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 17 18 3.016668 $146.3100 $48.5000
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Subtotal (Total Children Is Unduplicated) 136 146 19.055549 $975.6000 $51.2000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 16 19 7.088889 $10633.3500 $1500.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 158 193 0.983376 $49.3800 $50.2100
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 5 5 0.012501 $0.3200 $25.2000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 163 184 276.198417 $13809.9500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 52 57 81.277780 $4063.9000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 70 73 103.803174 $5190.1600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 177 196 272.877782 $13643.9100 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 162 184 975.904757 $48795.2600 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 9 9 67.428571 $3371.4300 $50.0000
INTR -INTR INTERPRETER 27 30 176.800001 $8840.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 35 39 204.674601 $13893.3300 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 38 43 267.098410 $18130.6300 $67.8800
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 0.722222 $164.6600 $227.9900
SENS -V5264 EARMOLD 1 1 0.722222 $13.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 38 45 273.285715 $18550.6500 $67.8800
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 262 592 145901.626990 $72950.8100 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 17 21 121.214287 $6060.7200 $50.0000
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Subtotal (Total Children Is Unduplicated) 303 1692 148731.719695 $238161.4400 $1.6000
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Total 1879 148844.419689 $239137.0400 $1.6100
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Number of Children (Unduplicated) With at Least One Authorization 393