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: 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
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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 2 2 2.00 $120.00 $60.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 4.29 $535.71 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 4 6 7.00 $350.00 $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 3 3 3.00 $145.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 26 26 22.26 $1079.66 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 7 7 7.00 $339.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 31 31 24.06 $1166.96 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 65 65 56.03 $2717.66 $48.50
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Subtotal (Total Children Is Unduplicated) 145 213 245.14 $15027.10 $61.30
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 3 2.50 $125.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 25 29 28.43 $1421.67 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 1.77 $44.17 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 14 15 11.33 $566.67 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 17 17 12.00 $600.00 $50.00
CONPP -CONPP CONSULT, PT, PHONE 2 2 1.77 $44.17 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 27 27 25.19 $1259.29 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.77 $19.17 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 0.14 $1.79 $12.50
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 216 230 1284.58 $64228.80 $50.00
INTR -INTR INTERPRETER 3 3 15.00 $750.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 34 34 215.05 $14597.43 $67.88
OCCT -97530HM OT SESSION BY OT ASST 11 11 96.00 $5214.72 $54.32
PHY -97110 PT SESSION BY LICENSED PT 47 47 352.21 $23908.29 $67.88
PHY -97110HM PT SESSION BY PT ASST 13 13 85.57 $4648.24 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 22 22 21.53 $21.53 $1.00
SENS -V5264 EARMOLD 2 3 4.00 $74.88 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 86 93 609.60 $41379.97 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 27 29 156.43 $2064.92 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 5 6 735.57 $367.79 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 8.43 $421.43 $50.00
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Subtotal (Total Children Is Unduplicated) 378 590 3668.88 $163259.91 $44.50
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Total 804 3915.02 $178324.01 $45.55
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Number of Children (Unduplicated) With at Least One Authorization 395