Summary Report for FSPSAs Initiated During the Report Period Center: 03
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: 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 32 32 78.400000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 32 32 78.400000 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 23 26 8.399998 $407.3900 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 9 9 7.616667 $457.0000 $60.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.411111 $47.2800 $115.0000
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 12 12 3.100001 $150.3500 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 0.588889 $28.5600 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 8 8 2.022222 $98.0800 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 17 17 4.294445 $208.2800 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 0.161111 $16.1100 $99.9900
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Subtotal (Total Children Is Unduplicated) 120 133 27.155546 $1455.0700 $53.5800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 8 10 4.883333 $7324.9500 $1499.9900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 159 194 1.472265 $73.8300 $50.1400
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 5 5 0.012501 $0.3200 $25.2000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 152 166 313.487303 $15674.3700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 62 69 116.161109 $5808.0500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 57 63 97.896824 $4894.8300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 146 159 271.335717 $13566.8000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 150 164 1135.546838 $56777.3400 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 10 10 56.590477 $2829.5200 $50.0000
INTR -INTR INTERPRETER 22 24 215.736509 $10786.8300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 37 41 344.012700 $23351.5900 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 28 32 218.761906 $14849.5500 $67.8800
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 0.416667 $208.3500 $500.0400
SENS -V5264 EARMOLD 4 4 1.405556 $25.3000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 36 44 305.077780 $20708.6800 $67.8800
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 245 524 169911.950793 $84955.9800 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 18 20 104.885715 $5244.2900 $50.0000
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Subtotal (Total Children Is Unduplicated) 272 1530 173099.633993 $267080.5400 $1.5400
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Total 1695 173205.189539 $268535.6100 $1.5500
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Number of Children (Unduplicated) With at Least One Authorization 328