Summary Report for FSPSAs Ending During the Report Period Center: 51
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
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Subtotal (Total Children Is Unduplicated) 1 1 1.00 $37.00 $37.00
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 6 6 5.59 $335.34 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 3.00 $358.80 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 3 3 4.29 $214.29 $50.00
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 2 2 3.00 $225.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 3 3 6.00 $450.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 1.00 $55.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 5 5 10.00 $750.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 11 12 13.00 $630.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 2.00 $97.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 9 9 9.00 $436.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 18 18 18.00 $873.00 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.00 $50.00 $50.00
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Subtotal (Total Children Is Unduplicated) 47 66 77.87 $4625.93 $59.40
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 3 4 10.21 $510.72 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 72 82 127.43 $6371.67 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 29 30 39.41 $1970.42 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.50 $37.50 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 40 40 56.53 $2826.25 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 53 53 75.89 $3794.58 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 4 4 6.00 $150.00 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 56.00 $1400.00 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 19.29 $482.14 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 104 106 680.90 $34045.23 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 2 2 3.67 $183.33 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 1.67 $83.34 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 46 48 363.79 $24693.78 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 3.14 $170.72 $54.32
PHY -97110 PT SESSION BY LICENSED PT 56 58 430.99 $29255.31 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 1.00 $1.00 $1.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 3.00 $711.36 $237.12
SENS -V5264 EARMOLD 4 4 1.43 $26.83 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 2 2 4.37 $218.33 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 0.77 $38.34 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 90 94 657.85 $44655.03 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 10.14 $133.89 $13.20
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 1 1 1.97 $98.34 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 2.73 $136.67 $50.00
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Subtotal (Total Children Is Unduplicated) 170 545 2560.67 $153494.76 $59.94
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Total 612 2639.55 $158157.68 $59.92
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Number of Children (Unduplicated) With at Least One Authorization 194