Summary Report for FSPSAs Ending During the Report Period Center: 54
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
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 41 44 42.62 $2557.48 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 5.00 $598.00 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 1.00 $125.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 3 3 3.00 $375.00 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 22 22 28.00 $1400.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 4 5 6.00 $450.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.00 $75.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 3 3 5.30 $397.50 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 3.80 $285.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 5 5 5.50 $305.25 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 5.29 $396.43 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 12 12 12.00 $582.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 33 34 34.00 $1649.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 10 10 10.00 $485.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 12 13 13.00 $630.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 52 54 55.00 $2667.50 $48.50
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 152 217 232.51 $13072.25 $56.22
EI Services, Class # 03
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.00 $68.86 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 8 8 12.50 $625.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 5 5 6.37 $318.33 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 52 55 106.85 $5342.61 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 6 6 2.63 $65.70 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 29 31 49.91 $2495.48 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 15 15 22.03 $1101.67 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 67 71 112.55 $5627.51 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 8 8 5.68 $142.09 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 167 177 1190.99 $59549.51 $50.00
INTR -INTR INTERPRETER 15 15 67.68 $3383.93 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 82 85 590.37 $40074.18 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 5.00 $271.60 $54.32
PHY -97110 PT SESSION BY LICENSED PT 60 63 355.96 $24162.84 $67.88
PHY -97110HM PT SESSION BY PT ASST 4 4 29.00 $1575.29 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 13 13 16.72 $16.72 $1.00
SENS -V5264 EARMOLD 4 4 2.69 $50.34 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 4 5 27.45 $1372.38 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 119 127 859.80 $58363.55 $67.88
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 269 422 169258.40 $84629.20 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 5 5 26.50 $1325.00 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 312 1122 172750.09 $290561.76 $1.68
-----------------------------------------------------------------------------------------------------------------------------
Total 1339 172982.60 $303634.02 $1.76
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 330