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: 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 7 7 7.833334 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 7 7 7.833334 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 8 9 2.149999 $104.2700 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 1.253968 $56.7800 $45.2800
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 3 0.388889 $17.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 0.477778 $54.9500 $115.0100
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 107 113 33.031743 $1602.0300 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 86 91 27.353973 $1326.6900 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 37 38 10.722223 $520.0300 $48.5000
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Subtotal (Total Children Is Unduplicated) 222 258 75.378573 $3682.2500 $48.8500
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 13.874604 $693.7300 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1 1 0.066667 $3.3400 $50.0200
CONOF -CONOF CONSULT, OT, FACE TO FACE 14 15 7.355554 $367.7700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 26 29 18.877778 $943.8900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 3 3 6.194444 $309.7200 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 47 48 273.857143 $6846.4400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 534 587 3848.914277 $192445.8900 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 0.088889 $4.4500 $50.0100
OCCT -97530 OT SESSION BY LICENSED OT 148 159 969.207933 $65789.8700 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 3 3 28.571429 $1552.0000 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 123 135 775.858732 $52665.3400 $67.8800
PHY -97110HM PT SESSION BY PT ASST 3 3 31.428572 $1707.2000 $54.3200
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.150000 $9.7500 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 0.238889 $54.4700 $228.0100
SENS -V5264 EARMOLD 2 2 0.477778 $8.6000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 14 14 28.041270 $1402.0600 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 73 78 470.864287 $31962.2500 $67.8800
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 533 622 5438.069027 $54380.7200 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 3 3 16.857143 $8.4300 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 2.428571 $121.4300 $50.0000
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Subtotal (Total Children Is Unduplicated) 683 1710 11931.422987 $411277.3200 $34.4700
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Total 1975 12014.634894 $414959.5800 $34.5400
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Number of Children (Unduplicated) With at Least One Authorization 689