Summary Report for FSPSAs Ending During the Report Period Center: 04
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: 01-01-13 and 03-31-13 Date of Report: 05-17-13 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 14 12.199207 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 11 14 12.199207 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 12 12 3.261113 $158.1700 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 3 3 0.238889 $14.3300 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 0.205555 $9.2500 $44.9900
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 1.200000 $138.0000 $115.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 120 126 37.794441 $1833.0100 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 90 98 22.557935 $1094.0500 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 49 49 20.477779 $993.1800 $48.5000
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Subtotal (Total Children Is Unduplicated) 227 295 85.735712 $4240.0000 $49.4500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.494444 $2472.0000 $4999.5600
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 3.071429 $153.5800 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1 1 1.928571 $96.4300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 20 21 13.617457 $680.8600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 24 29 14.073015 $703.6500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 10 11 7.228571 $361.4300 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 55 65 427.714278 $10692.8800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 504 590 3453.096784 $172654.9200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 166 180 929.670628 $63106.0500 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 147 165 791.307138 $53713.9400 $67.8800
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 0.350000 $22.7500 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 0.350000 $79.8000 $228.0000
SENS -V5264 EARMOLD 3 3 0.700001 $12.6000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 13 13 21.795239 $1089.7700 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 93 100 483.375394 $32811.5400 $67.8800
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 505 651 5067.394418 $2533.7000 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 5 6.330951 $316.5500 $50.0000
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Subtotal (Total Children Is Unduplicated) 669 1844 11222.498318 $341502.4200 $30.4300
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Total 2153 11320.433237 $345742.4200 $30.5400
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Number of Children (Unduplicated) With at Least One Authorization 678