Summary Report for FSPSAs Initiated During the Report Period Center: 51
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 -AUDE UNSPECIFIED AUDE SERVICES 4 4 2.99 $179.33 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 4.00 $478.40 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 2 2 5.14 $257.15 $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 8 9 9.00 $436.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 9 9 9.00 $436.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 21 21 21.00 $1018.50 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.00 $50.00 $50.00
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Subtotal (Total Children Is Unduplicated) 45 63 75.13 $4611.87 $61.38
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 9.57 $659.09 $68.86
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 10.00 $688.60 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 16.57 $828.58 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 55 58 99.83 $4991.49 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 25 26 38.91 $1945.42 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.50 $37.50 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 30 30 43.28 $2164.17 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.22 $5.56 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 54 57 92.85 $4642.74 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 4 4 7.50 $187.50 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 70.00 $1750.00 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 2.86 $142.86 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 1.03 $51.67 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 7.57 $189.29 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 85 86 597.31 $29865.70 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 1 3.87 $193.34 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 45 48 379.93 $25789.55 $67.88
PHY -97110 PT SESSION BY LICENSED PT 52 54 371.29 $25203.04 $67.88
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 3.00 $711.36 $237.12
SENS -V5264 EARMOLD 4 4 2.42 $45.34 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 3 3 9.10 $455.01 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 85 89 602.54 $40900.13 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 0.64 $8.49 $13.20
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 1 1 3.27 $163.34 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 3.57 $178.57 $50.00
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Subtotal (Total Children Is Unduplicated) 163 483 2380.64 $143798.27 $60.40
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Total 547 2456.77 $148447.15 $60.42
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Number of Children (Unduplicated) With at Least One Authorization 172