Summary Report for FSPSAs Initiated During the Report Period Center: 57
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 2.711111 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 4 4 2.711111 $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 0.077778 $4.4300 $56.9600
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 0.788890 $38.2700 $48.5100
PSTH -97001 EVAL BY LICENSED PT, INITIAL 4 5 0.800001 $38.8000 $48.5100
SPCH -92506 SPEECH EVAL BY LICENSED SLP 15 16 4.050000 $196.4300 $48.5000
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Subtotal (Total Children Is Unduplicated) 22 31 10.094446 $624.6400 $61.8800
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 1.066667 $53.3400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 19 20 29.227777 $1461.3900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.488889 $12.2200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 17 17 6.611111 $330.5600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 178 180 163.215864 $8160.7500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 7 7 3.061111 $76.5300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 12 13 102.714286 $5135.7200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 3.000000 $203.6400 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 3 4 14.214286 $964.8700 $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 6 7 35.142857 $2385.4900 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 10.000000 $132.0000 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 233 411 35486.215862 $17743.1100 $0.5000
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Subtotal (Total Children Is Unduplicated) 241 666 35859.225376 $37184.3800 $1.0400
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Total 701 35872.030933 $37809.0300 $1.0500
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Number of Children (Unduplicated) With at Least One Authorization 256