Summary Report for FSPSAs Ending During the Report Period Center: 54
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 11.14 $412.29 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 11.14 $412.29 $37.00
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 41 41 40.81 $2448.86 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 9 9 9.00 $1076.40 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 4 5 10.00 $1250.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 3 3 8.29 $1035.71 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 10 12 14.00 $700.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 4.00 $300.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.50 $112.50 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 2 2 2.00 $150.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 3 3.00 $225.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 7 7 10.50 $582.75 $55.50
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 8 8 10.43 $505.79 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 32 35 35.00 $1697.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 7 9 11.43 $554.29 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 8 8 8.00 $388.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 74 77 79.43 $3852.29 $48.50
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Subtotal (Total Children Is Unduplicated) 151 226 251.39 $15057.25 $59.90
EI Services, Class # 03
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 11.00 $757.46 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 11.99 $599.29 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 3 3.65 $182.62 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 2.60 $65.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 85 90 109.62 $5480.91 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 4 4 3.14 $78.47 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 39 40 54.79 $2739.65 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 2 0.27 $6.67 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 19 19 19.84 $992.22 $50.00
CONPP -CONPP CONSULT, PT, PHONE 3 3 3.18 $79.45 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 82 85 101.01 $5050.33 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 2 2 1.11 $27.78 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 161 175 1083.51 $54175.35 $50.00
INTR -INTR INTERPRETER 12 13 53.04 $2652.15 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 78 84 527.19 $35785.94 $67.88
OCCT -97530HM OT SESSION BY OT ASST 4 4 19.57 $1063.12 $54.32
PHY -97110 PT SESSION BY LICENSED PT 56 60 368.32 $25001.28 $67.88
PHY -97110HM PT SESSION BY PT ASST 6 6 22.05 $1197.50 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 17 17 17.00 $17.00 $1.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 1.00 $237.12 $237.12
SENS -V5264 EARMOLD 4 4 4.94 $92.56 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 7 7 33.52 $1676.20 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 126 137 876.45 $59493.26 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 9 9 54.29 $716.57 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 261 416 135458.38 $67729.19 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 6 6 36.71 $1835.71 $50.00
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Subtotal (Total Children Is Unduplicated) 323 1194 138878.17 $267732.78 $1.93
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Total 1421 139140.70 $283202.31 $2.04
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Number of Children (Unduplicated) With at Least One Authorization 347