Summary Report for FSPSAs Initiated During the Report Period Center: 54
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
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 1.00 $48.50 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 44 44 42.01 $2520.67 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 3.00 $140.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 17 17 18.00 $2152.80 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 3 3 9.29 $1160.71 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 3 3 3.00 $375.00 $125.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 1.00 $55.50 $55.50
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 8 8 8.00 $388.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 33 35 35.00 $1697.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 6 6 6.00 $291.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 9 9 9.00 $436.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 77 80 81.03 $3930.12 $48.50
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 143 211 217.33 $13232.76 $60.89
EI Services, Class # 03
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 2.14 $147.56 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 7 8 15.94 $796.91 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 2.53 $126.67 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.47 $11.67 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 83 87 133.31 $6665.58 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 6 6 6.83 $170.70 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 28 32 46.74 $2336.90 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 2 2.80 $70.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 17 19 28.07 $1403.62 $50.00
CONPP -CONPP CONSULT, PT, PHONE 2 2 2.27 $56.67 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 84 85 117.91 $5895.27 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 2 2 3.67 $91.67 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 49.29 $616.07 $12.50
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 157 164 1115.19 $55759.32 $50.00
INTR -INTR INTERPRETER 9 9 67.41 $3370.72 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 67 74 506.71 $34395.61 $67.88
OCCT -97530HM OT SESSION BY OT ASST 4 4 47.00 $2553.03 $54.32
PHY -97110 PT SESSION BY LICENSED PT 57 60 329.93 $22395.90 $67.88
PHY -97110HM PT SESSION BY PT ASST 9 9 56.04 $3043.85 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 14 14 14.00 $14.00 $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 1 1 1.00 $237.12 $237.12
SENS -V5264 EARMOLD 5 5 5.91 $110.66 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 8 8 28.41 $1420.72 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 127 131 797.58 $54139.49 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 40.71 $537.43 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 266 405 103003.14 $51501.57 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 9.14 $457.15 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 340 1139 106436.13 $249325.81 $2.34
-----------------------------------------------------------------------------------------------------------------------------
Total 1350 106653.46 $262558.57 $2.46
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 348