Summary Report for FSPSAs Ending During the Report Period Center: 07
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 1 1 7.14 $264.29 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 7.14 $264.29 $37.00
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.00 $16.30 $16.30
AUDE -AUDE UNSPECIFIED AUDE SERVICES 8 8 8.00 $480.00 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.00 $239.20 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 3 3 4.25 $212.50 $50.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.00 $111.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 23 23 35.50 $2662.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 15 16 25.50 $1415.25 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 32 45 71.50 $5362.50 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 5 5 7.00 $509.46 $72.78
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 31 31 32.32 $1567.67 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 2.00 $97.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 30 31 22.12 $1072.70 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 77 78 63.94 $3101.15 $48.50
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Subtotal (Total Children Is Unduplicated) 179 247 278.13 $16972.23 $61.02
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 1.00 $50.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 2 2 1.00 $25.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 8 9 6.55 $327.50 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 1.33 $33.33 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 12 13 11.78 $588.82 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 11 12 9.23 $461.67 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 12 12 10.55 $527.50 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.33 $33.33 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 3 3 44.86 $560.71 $12.50
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 8.14 $203.57 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 189 206 1237.96 $61897.79 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 11.43 $571.43 $50.00
INTR -INTR INTERPRETER 1 1 2.73 $136.67 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 54 57 325.00 $22061.02 $67.88
OCCT -97530HM OT SESSION BY OT ASST 10 11 69.85 $3794.38 $54.32
PHY -97110 PT SESSION BY LICENSED PT 56 60 381.94 $25926.30 $67.88
PHY -97110HM PT SESSION BY PT ASST 17 17 111.82 $6074.13 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 32 32 37.17 $37.17 $1.00
SENS -FM FM RECEIVER HEARING AID 2 2 2.00 $3300.00 $1650.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 129 139 749.36 $50866.35 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 8.14 $442.32 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 18 18 110.43 $1457.65 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 3.25 $162.38 $50.00
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Subtotal (Total Children Is Unduplicated) 374 605 3147.85 $181039.03 $57.51
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Total 853 3433.13 $198275.55 $57.75
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Number of Children (Unduplicated) With at Least One Authorization 447