Summary Report for FSPSAs Ending During the Report Period Center: 01
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: 04/01/10 and 06/30/10 Date of Report: 08-17-10 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
SCTT -SCTT SERVICE COORDINATOR TRAVEL 3 3 9.00 $333.00 $37.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 3 3 9.00 $333.00 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 6 7 7.00 $339.50 $48.50
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 5.71 $61.71 $10.80
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 5.71 $310.74 $54.38
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 5.71 $181.77 $31.81
AUDE -AUDE UNSPECIFIED AUDE SERVICES 18 18 18.00 $1080.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 8 8 10.00 $1196.00 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 4.00 $500.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 2 2 4.00 $200.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 110 117 225.25 $11262.50 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 39 40 80.00 $6000.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 3 3 6.00 $450.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 30 30 60.00 $4500.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 22 22 44.00 $2442.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 306 318 636.50 $47737.50 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 35 35 70.00 $5250.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 66 68 135.00 $10125.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 250 254 508.00 $28194.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 144 145 289.50 $21712.50 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 6 7 11.57 $561.21 $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 13 13 14.00 $679.00 $48.50
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.00 $15.00 $15.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 10 10 10.00 $485.00 $48.50
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 591 1107 2156.96 $143624.04 $66.59
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 8 13 13.00 $19500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 6 7 27.90 $1395.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 90 99 138.46 $6923.22 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 18 19 11.07 $276.79 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 16 17 22.07 $1103.34 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 10 13 19.08 $477.08 $25.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.60 $40.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 8 8 10.70 $535.00 $50.00
CONPP -CONPP CONSULT, PT, PHONE 3 3 4.73 $118.33 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 17 17 22.72 $1136.19 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 12 16 24.29 $607.32 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 21 28 200.86 $5021.43 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 17.57 $439.29 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 379 408 2295.10 $114755.03 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 5.00 $250.00 $50.00
INTR -INTR INTERPRETER 91 123 294.08 $14704.05 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 29 29 177.55 $12051.94 $67.88
PHY -97110 PT SESSION BY LICENSED PT 85 89 593.76 $40304.39 $67.88
PHY -97110HM PT SESSION BY PT ASST 4 4 35.71 $1940.00 $54.32
RSPT -RSPT RESPITE 1 1 38.40 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 47 47 48.47 $48.47 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 3.00 $1500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 2.00 $130.00 $65.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 1.00 $114.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 1.00 $237.12 $237.12
SENS -V5264 EARMOLD 5 5 8.62 $161.41 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 3 15.43 $771.43 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 167 180 1180.28 $80117.23 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 11 11 102.83 $1357.31 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 4.86 $485.71 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 579 811 4295.47 $2147.73 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 12.43 $621.43 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 689 1964 9629.04 $309270.21 $32.12
-----------------------------------------------------------------------------------------------------------------------------
Total 3074 11795.01 $453227.25 $38.43
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 1067