Summary Report for FSPSAs Initiated During the Report Period Center: 57
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 4 4 2.066666 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 4 4 2.066666 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 5 5 1.116667 $69.9400 $62.6300
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 1.527776 $175.6700 $114.9900
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 0.194444 $9.4300 $48.4900
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 23 23 6.011109 $291.5300 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 32 32 18.695241 $906.7400 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 55 58 15.344445 $744.2100 $48.5000
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Subtotal (Total Children Is Unduplicated) 103 124 42.889682 $2197.5200 $51.2400
EI Services, Class # 03
CONOF -CONOF CONSULT, OT, FACE TO FACE 36 38 46.528571 $2326.4300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 29 30 16.752380 $837.6200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 215 222 174.109527 $8705.4900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 1.594444 $39.8600 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 41 44 279.999999 $7000.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 265 276 2095.686500 $104784.3100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 46 51 238.785711 $16208.7900 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 4 4 25.321428 $1375.4600 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 53 54 303.785710 $20621.0000 $67.8800
PHY -97110HM PT SESSION BY PT ASST 2 2 4.077778 $221.5100 $54.3200
SENS -V5264 EARMOLD 2 2 0.755556 $13.6000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 2.022222 $101.1100 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 77 81 450.291667 $30565.8100 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 3.071429 $166.8400 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 26.785715 $353.5700 $13.2000
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 235 468 1923.542056 $19235.4200 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 67 82 2319.534917 $1159.7700 $0.5000
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Subtotal (Total Children Is Unduplicated) 376 1366 7912.645610 $213716.5700 $27.0100
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Total 1494 7957.601958 $215914.0900 $27.1300
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Number of Children (Unduplicated) With at Least One Authorization 387