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: 04/01/09 and 06/30/09 Date of Report: 08-25-09 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 1 1 11.14 $412.29 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 6 6 2.75 $101.75 $37.00
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Subtotal (Total Children Is Unduplicated) 7 7 13.89 $514.04 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 8 10 11.00 $533.50 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
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 -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.00 $31.81 $31.81
AUDE -AUDE UNSPECIFIED AUDE SERVICES 22 23 23.00 $1380.00 $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 13.00 $1554.80 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 4 4 4.75 $237.50 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 52 65 116.00 $5800.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 13 13 20.50 $1537.50 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 5 5 6.50 $487.50 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 9 9 11.50 $862.50 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 16 17 23.50 $1304.25 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 3 3 5.00 $277.50 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 282 284 415.14 $31135.72 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 23 23 35.50 $2662.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 53 53 66.64 $4998.22 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 216 217 309.50 $17177.25 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 249 254 333.50 $25012.51 $75.00
MED -MED UNSPECIFIED MED OFFICE VISIT 2 2 3.00 $450.00 $150.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 4 4 4.00 $194.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 3.00 $145.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 9 9 11.00 $533.50 $48.50
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Subtotal (Total Children Is Unduplicated) 536 1016 1426.04 $96564.17 $67.72
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 8 8 8.00 $12000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 2.00 $100.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 57 67 80.18 $4008.93 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 4 4 2.25 $56.25 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 15 16 19.83 $991.67 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 2.70 $67.50 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 1 1 1.00 $50.00 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 13 18 13.71 $685.36 $50.00
CONPP -CONPP CONSULT, PT, PHONE 6 6 3.77 $94.17 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 16 16 17.20 $860.00 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 13 13 11.11 $277.77 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 16 16 379.13 $9478.21 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 219 231 1188.92 $59446.24 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 1.86 $92.86 $50.00
INTR -INTR INTERPRETER 44 47 200.52 $10026.08 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 49 54 343.64 $23326.48 $67.88
OCCT -97530HM OT SESSION BY OT ASST 4 4 19.57 $1063.11 $54.32
PHY -97110 PT SESSION BY LICENSED PT 93 98 544.64 $36970.42 $67.88
PHY -97110HM PT SESSION BY PT ASST 4 4 23.57 $1280.40 $54.32
RSPT -RSPT RESPITE 1 1 48.53 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 23 23 98.59 $98.59 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 4.00 $948.48 $237.12
SENS -V5264 EARMOLD 1 1 2.00 $37.44 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 0.84 $42.15 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 251 282 1801.63 $122294.73 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 16 17 115.46 $1524.13 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 526 780 3304.56 $1652.28 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 12.71 $635.71 $50.00
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Subtotal (Total Children Is Unduplicated) 644 1719 8253.94 $289108.93 $35.03
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Total 2742 9693.87 $386187.14 $39.84
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Number of Children (Unduplicated) With at Least One Authorization 933