Summary Report for FSPSAs Initiated During the Report Period Center: 04
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: 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 12 22.876191 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 11 12 22.876191 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 18 18 5.455553 $264.5800 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 0.727777 $43.6600 $59.9900
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 0.788889 $35.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 1.488889 $171.2200 $115.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 128 132 31.649990 $1534.9800 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 100 109 25.694442 $1246.1700 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 55 57 14.083337 $683.0600 $48.5000
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Subtotal (Total Children Is Unduplicated) 254 322 79.888877 $3979.1700 $49.8100
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 5.857142 $292.8600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 26 27 9.688891 $484.4600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 25 29 14.566664 $728.3200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 8 8 10.566665 $528.3300 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 47 48 238.438094 $5960.9700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 547 594 3620.257157 $181012.7900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 171 179 993.610329 $67446.1700 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 150 164 848.614288 $57603.9100 $67.8800
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.383333 $24.9100 $64.9900
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 0.383333 $87.3900 $227.9800
SENS -V5264 EARMOLD 2 2 0.911111 $16.4000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 12 12 36.603175 $1830.1600 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 100 106 544.142860 $36936.4100 $67.8800
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 545 660 5363.280184 $2681.6500 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 5 6 37.230953 $1861.5500 $50.0000
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Subtotal (Total Children Is Unduplicated) 687 1839 11724.534179 $357496.2700 $30.4900
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Total 2173 11827.299247 $361475.4400 $30.5600
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Number of Children (Unduplicated) With at Least One Authorization 696