Summary Report for FSPSAs Ending During the Report Period Center: 03
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: 10-01-13 and 12-31-13 Date of Report: 02-18-14 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 8 8 17.733333 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 8 8 17.733333 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 19 20 4.705556 $228.2200 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 5 5 1.577778 $94.6700 $60.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 1.766668 $203.1800 $115.0100
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 5 5 1.800000 $87.3000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 4 4 0.688889 $33.4100 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 5 5 1.744444 $84.6000 $48.5000
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Subtotal (Total Children Is Unduplicated) 40 43 12.283335 $731.3900 $59.5400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 6 1.883333 $9416.5000 $4999.9100
CONIF -CONIF CONSULT ITDS, FACE TO FACE 179 179 268.364285 $13418.2100 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 44 44 77.666668 $3883.3400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 81 81 109.733331 $5486.6600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 156 156 237.141276 $11857.0900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 170 170 858.769841 $42938.5100 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 11 11 69.304762 $3465.2500 $50.0000
INTR -INTR INTERPRETER 13 13 121.246032 $6062.3000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 30 30 239.333334 $16245.9600 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 34 34 205.457139 $13946.4600 $67.8800
PHY -97110HM PT SESSION BY PT ASST 1 1 11.142857 $605.2800 $54.3200
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 0.966667 $483.3500 $500.0200
SENS -V5264 EARMOLD 6 6 4.288890 $77.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 34 34 208.079363 $14124.4500 $67.8800
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 269 526 136327.666668 $68163.8300 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 6 6 31.976192 $1598.8100 $50.0000
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Subtotal (Total Children Is Unduplicated) 276 1298 138773.020638 $211773.1900 $1.5300
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Total 1349 138803.037306 $212504.5800 $1.5300
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Number of Children (Unduplicated) With at Least One Authorization 287