Summary Report for FSPSAs Ending During the Report Period Center: 53
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 11 12 5.388890 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 0.866667 $32.0700 $37.0000
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Subtotal (Total Children Is Unduplicated) 11 14 6.255557 $32.0700 $5.1300
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 5 5 4.033333 $195.6200 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 31 33 32.816666 $1969.0000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 5 5 2.322222 $104.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 11 12 12.828571 $1475.2900 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.000000 $125.0000 $125.0000
EXIT -EXIT EXIT ASSESSMENT 28 28 20.857457 $1042.8700 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 2 2.000000 $150.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 14 14 22.239726 $1667.9800 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 4 4 0.044444 $3.3300 $74.9300
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 19 19 24.284170 $1347.7700 $55.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 1.285714 $62.3600 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 5 5 3.005555 $145.7700 $48.5000
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Subtotal (Total Children Is Unduplicated) 87 129 126.717858 $8289.4700 $65.4200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 6 8.063079 $12094.5000 $1499.9900
AUD -92630 AUD REHAB PRELING HEARING LOSS 2 2 1.144444 $78.8000 $68.8600
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.238889 $16.4500 $68.8600
AUD -HA_FUP AUDIOLOGY SERVICES 10 10 17.284128 $864.2200 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 7 12 0.077782 $3.9100 $50.2700
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.005556 $0.1400 $25.2000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 50 189 252.163499 $12608.2100 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 3 3 1.305555 $32.6400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 21 21 42.277779 $2113.8900 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 22 23 32.442857 $1622.1500 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.600000 $15.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 36 37 69.284923 $3464.2600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 7.000001 $175.0000 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 5 7 12.342858 $904.9900 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 14 15 42.847621 $1071.1900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 170 207 855.349234 $42767.4500 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 9 9 11.915874 $595.8000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 6 6 8.609523 $584.4200 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 1 1 3.428571 $186.2400 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 8 8 41.857142 $2841.2700 $67.8800
PHY -97110HM PT SESSION BY PT ASST 7 8 48.000000 $2607.3600 $54.3200
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 2.155556 $140.1100 $65.0000
SENS -V5264 EARMOLD 5 5 2.855556 $51.4000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 8 8 8.433334 $421.6700 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 7 7 32.109525 $2179.5900 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 3.714286 $49.0300 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 187 489 75871.620565 $37935.8100 $0.5000
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Subtotal (Total Children Is Unduplicated) 209 1084 77377.128137 $125425.4900 $1.6200
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Total 1227 77510.101552 $133747.0300 $1.7300
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Number of Children (Unduplicated) With at Least One Authorization 230