Summary Report for FSPSAs Ending During the Report Period Center: 57
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 7 7 2.955555 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 7 7 2.955555 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 8 8 2.627779 $164.5900 $62.6300
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 9.708730 $1116.5000 $115.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 21 21 15.741271 $763.4600 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 56 56 35.190477 $1706.7500 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 73 79 27.135721 $1316.1200 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 0.142857 $14.2900 $100.0300
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Subtotal (Total Children Is Unduplicated) 142 169 90.546835 $5081.7000 $56.1200
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 0.488889 $24.4500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 36 39 47.530953 $2376.5500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.877778 $21.9500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 22 26 29.088097 $1454.4200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 258 275 182.171437 $9108.6000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 0.500000 $12.5000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 40 45 269.714281 $6742.8700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 323 353 2254.929341 $112746.5400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 65 73 332.321426 $22558.0200 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 74 74 343.509520 $23317.4600 $67.8800
SENS -V5264 EARMOLD 2 3 4.309524 $77.5700 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 0.611111 $30.5600 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 113 124 620.552376 $42123.1900 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 12.142857 $659.6000 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 3.214286 $42.4300 $13.2000
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 278 559 2006.503163 $20065.0500 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 65 78 2758.981745 $1379.4900 $0.5000
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Subtotal (Total Children Is Unduplicated) 454 1658 8867.446784 $242741.2200 $27.3700
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Total 1834 8960.949174 $247822.9200 $27.6600
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Number of Children (Unduplicated) With at Least One Authorization 466