Summary Report for FSPSAs Initiated During the Report Period Center: 54
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
AUDE -AUDE UNSPECIFIED AUDE SERVICES 58 58 47.91 $2874.66 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 8 8 8.00 $374.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 5.00 $598.00 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 2 2 3.36 $419.64 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 39 40 46.00 $2300.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 4 4 5.00 $375.00 $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 2 2 2.50 $187.50 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 3 3 3.00 $225.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 4 4 4.50 $249.75 $55.50
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 7 7 7.00 $339.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 32 34 57.00 $2764.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 3 3 3.00 $145.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 8 8 8.00 $388.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 61 63 64.00 $3104.00 $48.50
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Subtotal (Total Children Is Unduplicated) 177 242 265.27 $14420.45 $54.36
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 9 9 17.17 $858.58 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 9 9 11.81 $590.55 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 49 52 66.61 $3330.32 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 5 5 0.93 $23.34 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 20 21 29.79 $1489.45 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 13 14 21.02 $1050.88 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.06 $1.53 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 72 73 81.30 $4065.00 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 7 7 2.87 $71.81 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 36.86 $460.71 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 8.00 $200.00 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 8.43 $210.72 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 164 173 1017.76 $50888.09 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 7 7 15.30 $765.25 $50.00
INTR -INTR INTERPRETER 24 26 130.70 $6535.24 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 63 64 435.25 $29544.77 $67.88
OCCT -97530HM OT SESSION BY OT ASST 3 3 20.79 $1129.08 $54.32
PHY -97110 PT SESSION BY LICENSED PT 38 42 257.02 $17446.34 $67.88
PHY -97110HM PT SESSION BY PT ASST 2 2 16.36 $888.52 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 14 14 11.09 $11.09 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 2.00 $1000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.00 $65.00 $65.00
SENS -V5264 EARMOLD 7 7 4.80 $89.86 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 10 10 29.55 $1477.63 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 89 96 573.56 $38933.18 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 10.43 $566.48 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 37.25 $491.70 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 287 437 154492.19 $77246.10 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 8 8 40.52 $2026.19 $50.00
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Subtotal (Total Children Is Unduplicated) 327 1091 157380.43 $241457.36 $1.53
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Total 1333 157645.69 $255877.81 $1.62
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Number of Children (Unduplicated) With at Least One Authorization 355