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) 1 1 0.150000 $9.3900 $62.6300
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 0.577777 $66.4400 $114.9800
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 5 5 0.972222 $47.1500 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 0.105556 $5.1200 $48.5200
SPCH -92506 SPEECH EVAL BY LICENSED SLP 9 9 2.633333 $127.7200 $48.5000
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Subtotal (Total Children Is Unduplicated) 15 18 4.438888 $255.8200 $57.6300
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
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 15 17 115.999999 $5800.0100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 13.357143 $906.6800 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 3 3 18.214286 $1236.3900 $67.8800
SENS -V5264 EARMOLD 1 1 0.288889 $5.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 9 9 60.464287 $4104.3100 $67.8800
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) 275 875 4690.386499 $44357.1600 $9.4600
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Total 897 4696.892053 $44612.9800 $9.5000
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Number of Children (Unduplicated) With at Least One Authorization 282