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: 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
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 1.00 $37.00 $37.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 1 1 1.00 $37.00 $37.00
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 2.00 $32.60 $16.30
AUDE -AUDE UNSPECIFIED AUDE SERVICES 4 4 4.00 $240.00 $60.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 4.29 $535.71 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 2 3 3.00 $150.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.00 $150.00 $75.00
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 11 11 18.50 $1387.50 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 1.50 $112.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 7 7 12.00 $666.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 34 49 81.50 $6112.50 $75.00
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 29 29 28.00 $1358.23 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 6 6 5.04 $244.65 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 25 25 26.57 $1288.44 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 65 68 53.36 $2588.00 $48.50
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 156 214 249.76 $15268.14 $61.13
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.00 $3000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 2.00 $100.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 3 2.50 $125.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 6 6 4.50 $225.00 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 5 5 5.47 $136.67 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 7 7 4.50 $225.00 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 6 6 3.60 $180.00 $50.00
CONPP -CONPP CONSULT, PT, PHONE 4 4 6.75 $168.87 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 12 13 8.50 $425.00 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 4 4 5.85 $146.37 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 2 2 42.57 $532.14 $12.50
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 219 229 1414.00 $70700.23 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 4 4 22.54 $1126.91 $50.00
INTR -INTR INTERPRETER 1 1 4.71 $235.72 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 33 35 180.93 $12281.45 $67.88
OCCT -97530HM OT SESSION BY OT ASST 8 9 57.57 $3127.28 $54.32
PHY -97110 PT SESSION BY LICENSED PT 45 45 301.40 $20458.73 $67.88
PHY -97110HM PT SESSION BY PT ASST 13 13 93.00 $5051.76 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 28 28 28.63 $28.63 $1.00
SENS -FM FM RECEIVER HEARING AID 1 1 1.00 $1650.00 $1650.00
SENS -V5264 EARMOLD 1 1 0.69 $12.90 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 103 108 766.25 $52012.87 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 7.29 $395.76 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 30 34 220.64 $2912.48 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 5 5 1896.57 $948.29 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 5 5 57.06 $2852.86 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 377 573 5140.53 $179059.89 $34.83
-----------------------------------------------------------------------------------------------------------------------------
Total 788 5391.29 $194365.03 $36.05
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 441