Summary Report for FSPSAs Initiated During the Report Period Center: 54
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 -AUDE UNSPECIFIED AUDE SERVICES 42 42 42.83 $2570.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 3.00 $140.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 4.00 $478.40 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 2 2.00 $250.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 3 3 8.43 $1053.58 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 18 20 23.00 $1150.00 $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 5 5 7.50 $416.25 $55.50
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 6 6 6.00 $291.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 23 26 26.00 $1261.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 7 9 21.14 $1025.43 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 9 9 9.00 $436.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 50 53 53.00 $2570.50 $48.50
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Subtotal (Total Children Is Unduplicated) 138 190 216.40 $12430.55 $57.44
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 4 4 3.78 $188.89 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 3 7.07 $353.34 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 46 48 72.04 $3602.23 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 6 6 5.48 $136.95 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 30 33 53.13 $2656.32 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 3 5.67 $141.67 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 9 10 15.21 $760.56 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.83 $20.83 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 73 76 120.53 $6026.62 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 7 7 4.62 $115.56 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 38.57 $482.14 $12.50
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 153 165 1181.10 $59054.87 $50.00
INTR -INTR INTERPRETER 15 15 97.50 $4875.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 61 67 447.46 $30373.48 $67.88
OCCT -97530HM OT SESSION BY OT ASST 4 4 25.43 $1381.28 $54.32
PHY -97110 PT SESSION BY LICENSED PT 43 47 267.65 $18168.41 $67.88
PHY -97110HM PT SESSION BY PT ASST 4 4 35.07 $1905.08 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 10 10 10.68 $10.68 $1.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 1.00 $237.12 $237.12
SENS -V5264 EARMOLD 2 2 2.52 $47.25 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 6 7 34.30 $1715.01 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 111 122 894.59 $60724.50 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 5.36 $291.00 $54.32
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 253 408 155682.40 $77841.20 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 20.14 $1007.14 $50.00
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Subtotal (Total Children Is Unduplicated) 301 1048 159032.13 $272117.08 $1.71
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Total 1238 159248.53 $284547.64 $1.79
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Number of Children (Unduplicated) With at Least One Authorization 312