Summary Report for FSPSAs Initiated During the Report Period Center: 01
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: 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 1 1 2.00 $74.00 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 2.00 $74.00 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 6 6 6.00 $291.00 $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 10 10 10.00 $600.00 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 6 6 6.00 $717.60 $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 305 317 634.50 $47587.50 $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 249 253 506.00 $28083.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 144 145 289.50 $21712.50 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 7 8 12.57 $609.71 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 10 10 10.00 $485.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 12 12 12.00 $582.00 $48.50
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Subtotal (Total Children Is Unduplicated) 572 1090 2134.96 $142150.54 $66.58
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 8 15 15.00 $22500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 3.00 $150.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 90 99 152.27 $7613.34 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 19 21 18.10 $452.38 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 24 25 37.10 $1855.24 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 12 14 14.90 $372.50 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 2 2 3.63 $181.67 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 10 10 13.10 $655.00 $50.00
CONPP -CONPP CONSULT, PT, PHONE 5 5 7.80 $195.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 15 15 35.37 $1768.34 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 9 12 10.89 $272.20 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 20 22 108.00 $2700.01 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 10.43 $260.72 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 411 420 2638.95 $131947.41 $50.00
INTR -INTR INTERPRETER 103 136 319.43 $15971.44 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 26 26 199.06 $13511.99 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 8.00 $434.56 $54.32
PHY -97110 PT SESSION BY LICENSED PT 91 94 666.20 $45221.98 $67.88
PHY -97110HM PT SESSION BY PT ASST 2 2 10.57 $574.24 $54.32
RSPT -RSPT RESPITE 1 1 10.13 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 45 46 56.16 $56.16 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 3 5.71 $285.72 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 136 145 933.65 $63375.85 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 10 10 61.00 $805.20 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 4.86 $485.71 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 617 809 4346.02 $2173.01 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 2.71 $135.72 $50.00
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Subtotal (Total Children Is Unduplicated) 707 1939 9692.03 $313955.36 $32.39
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Total 3030 11829.00 $456179.90 $38.56
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Number of Children (Unduplicated) With at Least One Authorization 907