Summary Report for FSPSAs Ending During the Report Period Center: 55
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 11 11 3.950001 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 11 11 3.950001 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 2 8.007828 $360.3500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.611111 $70.2800 $115.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 4 4 1.953968 $94.7700 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 7 7 1.899999 $92.1500 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 4 4 1.105555 $53.6200 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 7 7 2.244444 $108.8500 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 19 19 4.751598 $230.4500 $48.5000
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Subtotal (Total Children Is Unduplicated) 29 44 20.574503 $1010.4600 $49.1100
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 4 4 1.998174 $99.9100 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 19 19 4.317426 $215.8600 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 18 18 26.300003 $657.5100 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 4 4 0.372603 $18.6300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 4 4 4.533333 $113.3300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 9 9 2.438887 $121.9400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 11 11 19.200003 $480.0100 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 11 11 3.905556 $195.2800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 6 6 7.000001 $175.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 32 32 161.714288 $8085.7200 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 5 5 33.352381 $1667.6200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 41 41 219.285712 $14885.1200 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 3 3 9.714286 $527.6800 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 33 33 223.690476 $15184.1100 $67.8800
PHY -97110HM PT SESSION BY PT ASST 6 6 17.071430 $927.3200 $54.3200
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.611111 $39.7200 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 0.611111 $139.3300 $228.0000
SENS -V5264 EARMOLD 1 1 0.611111 $11.0000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 9.428571 $471.4300 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 100 100 623.764291 $42341.0800 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 9.571429 $519.9200 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 5 6 30.000000 $396.0000 $13.2000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 153 228 83134.650621 $41567.3300 $0.5000
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Subtotal (Total Children Is Unduplicated) 163 545 84544.142804 $128840.8400 $1.5200
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Total 600 84568.667308 $129851.3000 $1.5400
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Number of Children (Unduplicated) With at Least One Authorization 175