Summary Report for FSPSAs Ending During the Report Period Center: 01
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: 01/01/09 and 03/31/09 Date of Report: 05-18-09 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
SCTT -SCTT SERVICE COORDINATOR TRAVEL 4 4 14.79 $547.07 $37.00
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Subtotal (Total Children Is Unduplicated) 4 4 14.79 $547.07 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 2 2.00 $97.00 $48.50
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.00 $54.38 $54.38
AUDE -AUDE UNSPECIFIED AUDE SERVICES 14 14 13.82 $829.33 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 5.00 $598.00 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 3 3 5.50 $275.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 35 37 52.46 $2623.22 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 18 18 23.50 $1762.50 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.00 $75.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 4 4 7.00 $525.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 6 7 10.50 $787.50 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 18 18 25.50 $1415.25 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 193 193 273.00 $20475.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 8 8 11.00 $825.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 67 67 105.50 $7912.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 193 194 267.00 $14818.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 195 199 267.00 $20025.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 6 6 6.00 $291.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 5 5 5.00 $242.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 4 4 4.00 $194.00 $48.50
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Subtotal (Total Children Is Unduplicated) 410 787 1086.79 $73872.48 $67.97
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 7 7.00 $10500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 5 6 7.23 $361.67 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 42 46 58.39 $2919.65 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 9 9 3.25 $81.25 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 4 5 5.78 $289.17 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 11 12 21.61 $540.36 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 4 4 4.25 $212.50 $50.00
CONPP -CONPP CONSULT, PT, PHONE 4 4 7.69 $192.14 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 11 11 13.93 $696.32 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 14 15 14.80 $369.89 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 15 16 104.07 $2601.79 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 7.57 $378.57 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 195 204 1070.88 $53544.06 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 2.00 $100.00 $50.00
INTR -INTR INTERPRETER 20 22 127.30 $6364.75 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 30 32 252.86 $17163.95 $67.88
OCCT -97530HM OT SESSION BY OT ASST 4 4 24.29 $1319.20 $54.32
PHY -97110 PT SESSION BY LICENSED PT 75 79 557.93 $37872.52 $67.88
PHY -97110HM PT SESSION BY PT ASST 4 4 39.71 $2157.28 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 34 35 122.12 $122.12 $1.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.00 $65.00 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 1.00 $237.12 $237.12
SENS -V5264 EARMOLD 3 3 3.24 $60.62 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 3 7.00 $350.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 246 282 1632.82 $110835.80 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 9.43 $512.16 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 26 33 189.43 $2500.46 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 461 666 2883.97 $1441.98 $0.50
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Subtotal (Total Children Is Unduplicated) 574 1509 7180.55 $253790.33 $35.34
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Total 2300 8282.12 $328209.87 $39.63
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Number of Children (Unduplicated) With at Least One Authorization 796