Summary Report for FSPSAs Initiated During the Report Period Center: 54
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 4 4 9.293651 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 4 4 9.293651 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 3 3 2.505556 $121.5200 $48.5000
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 0.177778 $10.1200 $56.9500
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 0.788889 $47.3300 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 1.000000 $45.0000 $45.0000
EXIT -EXIT EXIT ASSESSMENT 14 18 19.436376 $971.8100 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 0.855556 $64.1700 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 1.800000 $99.9000 $55.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 2 2 0.735464 $35.6700 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 1 1 0.500000 $24.2500 $48.5000
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Subtotal (Total Children Is Unduplicated) 26 31 27.799619 $1419.7800 $51.0700
EI Services, Class # 03
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.433333 $29.8400 $68.8500
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 0.583257 $29.1700 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 4 15.649208 $782.4700 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.005556 $0.1400 $25.2000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 39 179 204.195830 $10209.7800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 8 8 20.979366 $1048.9700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 3.000000 $75.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 11 11 21.088889 $1054.4500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 14 14 20.749207 $1037.4600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 4.071429 $101.7900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 73 82 811.833339 $40591.6500 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 4.433334 $221.6700 $50.0000
INTR -INTR INTERPRETER 3 3 24.142857 $1207.1500 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 4 4 33.209524 $2254.2600 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 5 5 63.142857 $4286.1300 $67.8800
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 3 38.857143 $2637.6200 $67.8800
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 98 255 79830.343728 $39915.1700 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 12.571429 $628.5700 $50.0000
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Subtotal (Total Children Is Unduplicated) 106 578 81109.290286 $106111.2600 $1.3100
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Total 613 81146.383556 $107531.0400 $1.3300
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Number of Children (Unduplicated) With at Least One Authorization 120