Summary Report for FSPSAs Initiated During the Report Period Center: 07
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
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 7 7 7.00 $420.00 $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 33 46 72.50 $5437.50 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 4 4 6.00 $436.68 $72.78
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 4 4 4.00 $194.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 33 33 37.31 $1809.51 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 4 4 4.00 $194.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 21 21 24.74 $1199.76 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 78 78 66.64 $3232.25 $48.50
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Subtotal (Total Children Is Unduplicated) 161 244 293.44 $17705.45 $60.34
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.00 $3000.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.00 $68.86 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 1.00 $50.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 3.07 $153.34 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 3 3 2.45 $61.25 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 7 8 6.00 $300.00 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 4 4 4.20 $105.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 7 9 6.72 $335.84 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 3 3.32 $82.92 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 6 7 4.92 $245.84 $50.00
CONPP -CONPP CONSULT, PT, PHONE 3 3 2.20 $55.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 6 7 19.21 $960.48 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 7 7 7.32 $182.92 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 3 3 42.29 $528.57 $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 181 191 1270.51 $63525.65 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 2.03 $101.67 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 42 43 306.43 $20800.41 $67.88
OCCT -97530HM OT SESSION BY OT ASST 9 10 48.99 $2661.16 $54.32
PHY -97110 PT SESSION BY LICENSED PT 41 43 286.59 $19453.46 $67.88
PHY -97110HM PT SESSION BY PT ASST 7 7 55.25 $3001.18 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 20 21 21.17 $21.17 $1.00
SENS -FM FM RECEIVER HEARING AID 1 1 1.00 $1650.00 $1650.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 118 120 948.43 $64379.37 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 19 19 138.43 $1827.26 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 6 6 48.14 $24.07 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 43.71 $2185.72 $50.00
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Subtotal (Total Children Is Unduplicated) 340 525 3284.50 $185964.67 $56.62
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Total 769 3577.95 $203670.12 $56.92
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Number of Children (Unduplicated) With at Least One Authorization 364