Summary Report for FSPSAs Ending During the Report Period Center: 07
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 32 33 1171.058730 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 32 33 1171.058730 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 3 3 0.729377 $43.7600 $60.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 3 3 4.882551 $236.8000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 2 2 0.544445 $26.4100 $48.5000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.294444 $4.4200 $15.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 8 8 3.072223 $149.0100 $48.5000
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Subtotal (Total Children Is Unduplicated) 15 17 9.523040 $460.4000 $48.3500
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 0.294444 $14.7200 $49.9900
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 3 3 17.857143 $446.4300 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 65 74 425.499999 $21274.9900 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 1.866667 $46.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 15 15 61.428572 $3071.4300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 15 15 54.042859 $2702.1400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.733333 $68.3300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 25 25 135.647621 $6782.3800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 2.428571 $60.7200 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 5 5 70.285714 $1757.1400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 263 270 1602.754767 $80137.6600 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 4.680953 $234.0500 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 8 8 31.428572 $2133.3700 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 11 11 39.588888 $2687.2900 $67.8800
PHY -97110HM PT SESSION BY PT ASST 1 1 4.714286 $256.0800 $54.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 24 24 147.642855 $10022.0000 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 7 7 47.857144 $631.7100 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 257 299 123214.571420 $61607.2900 $0.5000
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Subtotal (Total Children Is Unduplicated) 300 763 125865.323808 $193934.3800 $1.5400
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Total 813 127045.905578 $194394.7800 $1.5300
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Number of Children (Unduplicated) With at Least One Authorization 334