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: 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
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 10.86 $401.71 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 7.21 $266.93 $37.00
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Subtotal (Total Children Is Unduplicated) 3 3 18.07 $668.64 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 4 4 5.00 $242.50 $48.50
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.00 $27.10 $27.10
AUDE -AUDE UNSPECIFIED AUDE SERVICES 14 14 15.00 $900.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 7 7 7.00 $837.20 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 3 3 4.64 $232.15 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 70 75 149.04 $7451.79 $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 19 19 34.00 $1887.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 230 230 393.00 $29475.00 $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 201 201 344.43 $19115.79 $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 1 1 1.00 $48.50 $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 5 6 6.00 $291.00 $48.50
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.00 $15.00 $15.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 13 13 14.00 $679.00 $48.50
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Subtotal (Total Children Is Unduplicated) 455 887 1488.25 $99553.53 $66.89
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 15 18 20.00 $30000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 2.00 $100.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 61 65 95.93 $4796.43 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 18 18 14.03 $350.78 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 9 11 13.61 $680.48 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 6 6 6.18 $154.59 $25.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 2.68 $67.09 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 5 5 8.30 $415.00 $50.00
CONPP -CONPP CONSULT, PT, PHONE 2 2 1.25 $31.25 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 20 20 44.71 $2235.48 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 17 17 28.99 $724.76 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 13 13 105.64 $2641.08 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 8.71 $217.86 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 367 375 2451.97 $122598.43 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 3.86 $192.86 $50.00
INTR -INTR INTERPRETER 58 62 274.94 $13747.15 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 29 30 200.66 $13620.94 $67.88
PHY -97110 PT SESSION BY LICENSED PT 91 99 656.30 $44549.66 $67.88
PHY -97110HM PT SESSION BY PT ASST 2 2 16.86 $915.68 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 43 44 48.97 $48.97 $1.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 3.00 $195.00 $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 2 2 1.48 $27.64 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 4 4 13.86 $692.86 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 183 194 1351.56 $91743.91 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 18 18 164.17 $2167.00 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 1.00 $100.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 558 745 4394.59 $2197.29 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 1.00 $50.00 $50.00
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Subtotal (Total Children Is Unduplicated) 647 1764 9940.25 $336087.53 $33.81
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Total 2654 11446.57 $436309.70 $38.12
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Number of Children (Unduplicated) With at Least One Authorization 771