Summary Report for FSPSAs Ending During the Report Period Center: 57
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 4.666665 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 13 13 4.666665 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 0.111111 $5.3900 $48.5000
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 0.177778 $10.1200 $56.9500
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 2.133333 $96.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.133333 $245.3300 $115.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 6 6 1.438889 $69.7900 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 7 8 1.416666 $68.7100 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 13 13 4.125398 $200.0800 $48.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 20 31 11.536508 $695.4100 $60.2800
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 1.066667 $53.3400 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1 1 0.261111 $13.0600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 10 10 12.243651 $612.1800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 18 18 24.974603 $1248.7300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 219 228 124.028574 $6201.4500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 5 1.588889 $39.7200 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 11.428571 $285.7200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 19 20 276.428571 $13821.4300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 5.071429 $344.2500 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 3 4 16.142857 $1095.7800 $67.8800
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.133333 $486.3900 $228.0000
SENS -V5264 EARMOLD 1 1 2.133333 $38.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 3 15.642857 $1061.8300 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 3.142857 $41.4900 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 285 538 41255.987298 $20627.9900 $0.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 289 833 41752.274601 $45971.7400 $1.1000
-------------------------------------------------------------------------------------------------------------------------------------
Total 877 41768.477774 $46667.1600 $1.1200
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 310