Summary Report for FSPSAs Initiated During the Report Period Center: 07
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
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 4 4 4.00 $240.00 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.00 $119.60 $119.60
EXIT -EXIT TRANSITION ASSESSMENT 3 3 4.50 $225.00 $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 33 45 83.50 $6262.50 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 1 1 2.00 $145.56 $72.78
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 8 8 8.00 $388.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 19 20 20.02 $971.08 $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 19 19 17.35 $841.48 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 82 83 81.58 $3956.71 $48.50
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Subtotal (Total Children Is Unduplicated) 143 200 247.45 $14885.42 $60.15
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 1 2 2.00 $100.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 4 4.50 $225.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 12 13 14.77 $738.34 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 5 5 7.42 $185.42 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 12 12 21.36 $1067.86 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 14 14 13.72 $686.12 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 14 15 30.87 $1543.57 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 8 8 6.41 $160.14 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 13.00 $162.50 $12.50
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 9.29 $464.29 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 242 252 1502.75 $75137.75 $50.00
INTR -INTR INTERPRETER 1 1 1.75 $87.50 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 43 45 278.06 $18874.87 $67.88
OCCT -97530HM OT SESSION BY OT ASST 13 16 94.00 $5106.09 $54.32
PHY -97110 PT SESSION BY LICENSED PT 51 53 366.12 $24852.48 $67.88
PHY -97110HM PT SESSION BY PT ASST 6 7 72.57 $3942.08 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 27 27 27.51 $27.51 $1.00
SENS -FM FM RECEIVER HEARING AID 1 1 1.00 $1650.00 $1650.00
SENS -V5264 EARMOLD 1 1 2.00 $37.44 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 131 135 959.07 $65101.81 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 26 26 223.51 $2950.32 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 17 18 86.00 $43.00 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 52.00 $2600.00 $50.00
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Subtotal (Total Children Is Unduplicated) 423 661 3790.68 $207244.06 $54.67
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Total 861 4038.13 $222129.48 $55.01
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Number of Children (Unduplicated) With at Least One Authorization 435