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: 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 9 9 7.705555 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 9 9 7.705555 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 10 11 2.994444 $145.2300 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 3 3 1.288889 $77.3300 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 1.288889 $58.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 2.577777 $296.4400 $115.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 0.066667 $3.2400 $48.5200
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 132 145 35.561112 $1724.7200 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 0.066667 $3.2400 $48.5200
PSTH -97001 EVAL BY LICENSED PT, INITIAL 81 85 24.632540 $1194.6800 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 50 53 22.047621 $1069.3200 $48.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 254 305 90.524606 $4572.1800 $50.5100
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 7 8 38.097620 $1904.8800 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1 2 0.177778 $8.8900 $50.0100
CONOF -CONOF CONSULT, OT, FACE TO FACE 12 12 6.933335 $346.6800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 23 26 7.899997 $394.9900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 6 7 8.283333 $414.1700 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 55 60 405.928561 $10148.2400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 528 610 3443.255502 $172162.9400 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 0.422222 $21.1100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 167 191 1111.017444 $75415.9300 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 2 2 22.000000 $1195.0400 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 119 136 657.285711 $44616.6000 $67.8800
PHY -97110HM PT SESSION BY PT ASST 1 1 6.857143 $372.4800 $54.3200
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 0.866667 $56.3400 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 1.288889 $293.8700 $228.0000
SENS -V5264 EARMOLD 6 6 8.941269 $160.9400 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 14 15 35.038094 $1751.9100 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 94 101 491.659523 $33373.8500 $67.8800
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 507 630 4976.630124 $49766.3100 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 5 5 40.571428 $20.2900 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 5 6 17.223809 $861.2000 $50.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 677 1824 11280.378449 $393286.6200 $34.8600
-------------------------------------------------------------------------------------------------------------------------------------
Total 2138 11378.608610 $397858.8000 $34.9700
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 686