Summary Report for FSPSAs Initiated During the Report Period Center: 01
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: 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 14.64 $541.79 $37.00
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Subtotal (Total Children Is Unduplicated) 4 4 14.64 $541.79 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 3 5 6.00 $291.00 $48.50
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.00 $8.83 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.00 $10.80 $10.80
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 1.00 $8.44 $8.44
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 2.00 $43.58 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.00 $54.38 $54.38
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.00 $31.81 $31.81
AUDE -AUDE UNSPECIFIED AUDE SERVICES 25 25 25.00 $1500.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 3.00 $140.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 10 10 11.00 $1315.60 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 2 2 3.50 $175.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 38 40 57.96 $2898.22 $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 195 195 275.00 $20625.00 $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 4 4 4.00 $194.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 8 8 8.00 $388.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 6 6 7.00 $339.50 $48.50
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Subtotal (Total Children Is Unduplicated) 406 819 1125.46 $76170.81 $67.68
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 6 6.00 $9000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 4 4 5.27 $263.34 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 44 48 61.33 $3066.31 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 12 12 5.25 $131.25 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 8 8 8.75 $437.50 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 5 6 3.70 $92.50 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 1 1 1.80 $90.00 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.20 $5.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 7 7 9.48 $474.17 $50.00
CONPP -CONPP CONSULT, PT, PHONE 4 4 5.24 $131.07 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 7 7 15.11 $755.36 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 12 13 6.32 $157.92 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 19 19 740.24 $18506.08 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 15.36 $767.86 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 256 268 1434.77 $71738.35 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 3 3 14.06 $702.86 $50.00
INTR -INTR INTERPRETER 35 37 178.81 $8940.48 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 35 35 226.07 $15345.73 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 12.57 $682.88 $54.32
PHY -97110 PT SESSION BY LICENSED PT 82 86 529.45 $35939.07 $67.88
PHY -97110HM PT SESSION BY PT ASST 5 5 40.86 $2219.36 $54.32
RSPT -RSPT RESPITE 2 2 70.93 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 28 29 32.17 $32.17 $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 2 2 3.00 $711.36 $237.12
SENS -V5264 EARMOLD 3 3 3.58 $67.09 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 4 13.57 $678.57 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 253 265 1772.46 $120314.39 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 1.00 $54.32 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 22 22 196.55 $2594.40 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 9.71 $971.43 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 485 765 3774.70 $1887.35 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 32.14 $1607.15 $50.00
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Subtotal (Total Children Is Unduplicated) 581 1671 9231.45 $298430.28 $32.33
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Total 2494 10371.55 $375142.87 $36.17
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Number of Children (Unduplicated) With at Least One Authorization 688