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: 10/01/09 and 12/31/09 Date of Report: 02-15-10 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
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 7.21 $266.93 $37.00
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Subtotal (Total Children Is Unduplicated) 2 2 7.21 $266.93 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 2 2.00 $97.00 $48.50
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.00 $27.10 $27.10
AUDE -AUDE UNSPECIFIED AUDE SERVICES 20 20 19.08 $1144.67 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 3.00 $140.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 7.00 $837.20 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 3 3 4.64 $232.15 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 69 74 147.04 $7351.79 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 21 21 35.50 $2662.50 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 4 4 6.50 $487.50 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 5 5 9.50 $712.50 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 18 18 30.00 $2250.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 20 20 34.30 $1903.65 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 229 229 391.00 $29325.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 43 43 74.00 $5550.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 29 29 47.93 $3594.65 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 200 200 342.43 $19004.79 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 187 187 304.71 $22853.57 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 2 2 6.29 $304.86 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 4 4 4.00 $194.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 9 10 10.00 $485.00 $48.50
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.00 $15.00 $15.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 11 11 17.29 $838.36 $48.50
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Subtotal (Total Children Is Unduplicated) 469 892 1498.20 $100011.67 $66.75
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 13 18 21.00 $31500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 9.57 $478.57 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 61 65 107.43 $5371.43 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 28 30 16.28 $407.03 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 16 17 18.05 $902.56 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 8 8 6.47 $161.67 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 4 4 5.11 $255.42 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 3.63 $90.83 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 5 6 5.41 $270.42 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 32 34 45.18 $2258.99 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 25 27 28.68 $717.09 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 10 12 55.14 $1378.58 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 284 304 1812.85 $90642.44 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 3.86 $192.86 $50.00
INTR -INTR INTERPRETER 70 74 320.39 $16019.53 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 36 40 216.41 $14689.57 $67.88
PHY -97110 PT SESSION BY LICENSED PT 93 108 569.19 $38636.95 $67.88
PHY -97110HM PT SESSION BY PT ASST 5 5 22.29 $1210.56 $54.32
RSPT -RSPT RESPITE 1 1 16.00 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 51 53 55.73 $55.73 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.00 $65.00 $65.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 1.00 $114.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 3.00 $711.36 $237.12
SENS -V5264 EARMOLD 3 3 5.00 $93.60 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 4 4 11.56 $577.86 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 249 279 1600.25 $108625.03 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 24 25 107.21 $1415.23 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 2 2 10.00 $1000.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 533 757 4058.00 $2028.99 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 22.57 $1128.57 $50.00
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Subtotal (Total Children Is Unduplicated) 639 1891 9160.26 $321999.85 $35.15
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Total 2785 10665.67 $422278.44 $39.59
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Number of Children (Unduplicated) With at Least One Authorization 945