Summary Report for FSPSAs Ending During the Report Period Center: 55
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 13 13 9.996826 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 13 13 9.996826 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 0.197260 $8.8700 $44.9900
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 1.849315 $212.6700 $115.0000
EXIT -EXIT EXIT ASSESSMENT 1 1 0.030137 $1.5100 $49.9400
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 13 13 5.950792 $288.6100 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 18 18 2.909209 $141.1000 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 7 7 1.244444 $60.3500 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 16 16 2.581279 $125.1900 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 45 45 13.036179 $632.2400 $48.5000
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Subtotal (Total Children Is Unduplicated) 76 104 27.798615 $1470.5400 $52.9000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.068493 $102.7500 $1500.1500
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 2.150000 $107.5000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 4 4 0.010960 $0.5400 $49.2700
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 2 3 0.505480 $12.6400 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 14 14 8.866894 $443.3400 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 20 20 30.033334 $750.8400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 9 12 3.308221 $165.4000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 11 14 15.766666 $394.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 4 4 0.438888 $21.9400 $49.9900
CONPP -CONPP CONSULT, PT, PHONE 6 6 5.100000 $127.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 8 8 2.672221 $133.6100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 10 10 14.966667 $374.1700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 28 28 180.571429 $9028.5600 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 3 3 10.373386 $518.6700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 50 55 283.964287 $19275.5000 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 4 4 14.428572 $783.7600 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 31 32 177.811904 $12069.8600 $67.8800
PHY -97110HM PT SESSION BY PT ASST 8 8 20.214284 $1098.0500 $54.3200
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 0.197260 $12.8200 $64.9800
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 0.197260 $44.9600 $227.9300
SENS -V5264 EARMOLD 2 2 0.800000 $14.4000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 3 13.428572 $671.4300 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 117 121 673.259534 $45700.8200 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 0.142857 $1.8900 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 177 263 83509.881915 $41754.9400 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 7.087671 $354.3900 $50.0000
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Subtotal (Total Children Is Unduplicated) 196 625 84976.246755 $133964.4100 $1.5800
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Total 742 85014.042196 $135434.9500 $1.5900
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Number of Children (Unduplicated) With at Least One Authorization 228