Summary Report for FSPSAs Ending During the Report Period Center: 01
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: 01/01/10 and 03/31/10 Date of Report: 05-17-10 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
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 0.25 $9.25 $37.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 2.00 $74.00 $37.00
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Subtotal (Total Children Is Unduplicated) 3 3 2.25 $83.25 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 5 6 8.00 $388.00 $48.50
AUDE -AUDE UNSPECIFIED AUDE SERVICES 20 20 20.00 $1200.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 3.00 $358.80 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.25 $62.50 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 67 72 141.00 $7050.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 40 41 74.50 $5587.50 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 7 7 14.00 $1050.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 8 8 15.00 $1125.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 39 39 73.00 $5475.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 23 23 42.00 $2331.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 364 412 773.71 $58028.22 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 57 63 120.50 $9037.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 87 96 176.50 $13237.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 337 388 728.21 $40415.63 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 215 240 441.00 $33075.00 $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 5 5 5.00 $242.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 2 2 4.00 $194.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 12 12 13.00 $630.50 $48.50
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Subtotal (Total Children Is Unduplicated) 615 1441 2656.67 $179632.45 $67.62
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 9 9 13.00 $19500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 3.36 $167.86 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 61 67 99.39 $4969.65 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 7 7 4.45 $111.25 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 12 13 16.83 $841.67 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 8 8 13.45 $336.25 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 5 5 8.83 $441.67 $50.00
CONOP -CONOP CONSULT, OT, PHONE 4 4 5.42 $135.42 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 8 9 13.53 $676.67 $50.00
CONPP -CONPP CONSULT, PT, PHONE 3 3 3.15 $78.75 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 18 18 28.78 $1439.05 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 9 9 14.37 $359.17 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 11 12 77.29 $1932.15 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 16.71 $417.86 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 310 337 2111.52 $105576.23 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 21.14 $1057.15 $50.00
INTR -INTR INTERPRETER 74 99 388.60 $19430.02 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 26 28 137.14 $9309.27 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 4.57 $248.32 $54.32
PHY -97110 PT SESSION BY LICENSED PT 79 83 550.79 $37387.96 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 8.29 $450.08 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 58 60 65.54 $65.54 $1.00
SENS -V5264 EARMOLD 2 2 5.00 $93.60 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 2.00 $100.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 167 185 1194.03 $81050.50 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 10 10 46.46 $613.33 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 513 686 4014.50 $2007.25 $0.50
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Subtotal (Total Children Is Unduplicated) 600 1665 8868.16 $288796.61 $32.57
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Total 3109 11527.08 $468512.31 $40.64
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Number of Children (Unduplicated) With at Least One Authorization 1043