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: 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 2 3 17.59 $650.85 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 6 6 2.75 $101.75 $37.00
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Subtotal (Total Children Is Unduplicated) 8 9 20.34 $752.60 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 6 6 6.00 $291.00 $48.50
AUDE -AUDE UNSPECIFIED AUDE SERVICES 34 34 33.94 $2036.66 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 8 9 12.00 $1435.20 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 4 4 4.75 $237.50 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 51 64 114.50 $5725.00 $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 17 18 25.53 $1417.10 $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 281 283 414.14 $31060.72 $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 248 253 332.50 $24937.51 $75.00
MED -MED UNSPECIFIED MED OFFICE VISIT 2 2 3.00 $450.00 $150.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 2 2 7.29 $353.36 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 2 2 2.00 $97.00 $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) 514 1011 1423.80 $96671.11 $67.90
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 9 11 12.00 $18000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 6 6 15.00 $750.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 56 66 77.68 $3883.93 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 6 6 2.75 $68.75 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 21 23 25.83 $1291.67 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 8 9 15.37 $384.17 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 4 4 4.53 $226.67 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.23 $55.83 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 14 18 12.41 $620.36 $50.00
CONPP -CONPP CONSULT, PT, PHONE 2 2 2.13 $53.33 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 27 28 29.30 $1465.00 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 9 10 18.23 $455.83 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 11 11 50.71 $1267.86 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 282 299 1637.32 $81866.12 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 11.14 $557.15 $50.00
INTR -INTR INTERPRETER 55 58 249.47 $12473.67 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 37 40 249.55 $16939.28 $67.88
OCCT -97530HM OT SESSION BY OT ASST 3 3 8.29 $450.08 $54.32
PHY -97110 PT SESSION BY LICENSED PT 88 92 648.48 $44018.55 $67.88
PHY -97110HM PT SESSION BY PT ASST 4 4 26.07 $1416.20 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 30 30 30.73 $30.73 $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 3 3 7.51 $140.61 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 4 4 15.38 $769.05 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 264 281 1805.52 $122558.77 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 14 14 112.39 $1483.58 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 513 853 3910.21 $1955.11 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 2.14 $107.15 $50.00
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Subtotal (Total Children Is Unduplicated) 623 1881 8988.39 $315237.90 $35.07
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Total 2901 10432.53 $412661.61 $39.56
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Number of Children (Unduplicated) With at Least One Authorization 748