Summary Report for FSPSAs Initiated During the Report Period Center: 53
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
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 3 3 4.00 $194.00 $48.50
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 64 64 65.64 $7851.07 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 6 6 8.00 $1000.00 $125.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 1.00 $55.50 $55.50
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 7 7 7.13 $356.67 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 17 17 23.41 $1135.37 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 19 19 26.14 $1267.93 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 25 27 37.14 $1801.43 $48.50
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Subtotal (Total Children Is Unduplicated) 107 146 174.47 $13755.56 $78.84
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.00 $4500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 4 4 9.14 $457.15 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 1.00 $25.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 16 16 16.73 $836.67 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 4 4 5.98 $149.58 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 7 7 12.30 $615.00 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 3.73 $93.33 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 4 4 5.13 $256.67 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 8 8 12.87 $643.33 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 6 6 9.08 $226.97 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 4.13 $303.47 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 36 37 87.13 $2178.22 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 191 199 993.48 $49673.83 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 4 4 22.55 $1127.38 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 1 2 66.00 $4480.08 $67.88
OCCT -97530HM OT SESSION BY OT ASST 22 23 150.12 $8154.72 $54.32
PHY -97110HM PT SESSION BY PT ASST 30 31 191.86 $10421.93 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 18 18 11.17 $11.17 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.43 $93.16 $65.00
SENS -V5264 EARMOLD 2 2 2.39 $44.72 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 4 4 8.23 $411.67 $50.00
SPL -92508 GROUP SPL SESSION PER CHILD 28 31 383.20 $5058.24 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 1.14 $57.15 $50.00
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Subtotal (Total Children Is Unduplicated) 253 409 2002.81 $90319.42 $45.10
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Total 555 2177.29 $104074.98 $47.80
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Number of Children (Unduplicated) With at Least One Authorization 257