Summary Report for FSPSAs Ending During the Report Period Center: 07
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
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 2.00 $120.00 $60.00
EXIT -EXIT TRANSITION ASSESSMENT 5 6 8.50 $425.00 $50.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.00 $111.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 10 10 17.50 $1312.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 3.00 $166.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 34 46 84.50 $6337.50 $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 29 31 37.42 $1814.67 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 6 6 6.00 $291.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 32 33 29.16 $1414.31 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 94 96 80.66 $3911.79 $48.50
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Subtotal (Total Children Is Unduplicated) 173 234 271.73 $15952.77 $58.71
EI Services, Class # 03
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.00 $68.86 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 2 3 3.00 $150.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 4 3.53 $176.67 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.27 $6.67 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 10 10 10.27 $513.34 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 6 6 10.47 $261.67 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 10 10 6.73 $336.67 $50.00
CONOP -CONOP CONSULT, OT, PHONE 4 4 2.47 $61.67 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 6 6 4.38 $219.17 $50.00
CONPP -CONPP CONSULT, PT, PHONE 4 4 8.20 $205.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 11 11 7.18 $358.81 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 8 8 13.23 $330.84 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 8.57 $107.14 $12.50
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 225 239 1503.63 $75181.53 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 12.54 $627.15 $50.00
INTR -INTR INTERPRETER 2 2 11.32 $566.07 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 43 43 220.26 $14951.05 $67.88
OCCT -97530HM OT SESSION BY OT ASST 11 12 69.58 $3779.38 $54.32
PHY -97110 PT SESSION BY LICENSED PT 48 52 316.18 $21462.20 $67.88
PHY -97110HM PT SESSION BY PT ASST 6 6 47.64 $2587.96 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 25 25 25.96 $25.96 $1.00
SENS -FM FM RECEIVER HEARING AID 2 2 2.00 $3300.00 $1650.00
SENS -V5264 EARMOLD 3 3 4.31 $80.70 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 129 139 782.36 $53106.41 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 26 27 182.87 $2413.84 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 13 14 651.57 $325.79 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 13.00 $650.00 $50.00
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Subtotal (Total Children Is Unduplicated) 408 636 3922.51 $181854.51 $46.36
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Total 870 4194.24 $197807.28 $47.16
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Number of Children (Unduplicated) With at Least One Authorization 468