Summary Report for FSPSAs Ending During the Report Period Center: 53
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
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 2 3.00 $145.50 $48.50
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 65 65 63.99 $7653.08 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 6 7 8.00 $1000.00 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 2 2 2.00 $100.00 $50.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 1.14 $63.43 $55.50
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 4 4 4.00 $200.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 9 9 9.00 $436.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 17 17 17.00 $824.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 28 28 28.71 $1392.64 $48.50
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Subtotal (Total Children Is Unduplicated) 109 136 137.85 $11862.46 $86.06
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 1.93 $2899.95 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 2 4 5.42 $271.19 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 11 11 14.40 $720.00 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 5 5 41.20 $1030.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 6 6 7.93 $396.67 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 4 4 5.37 $268.34 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.18 $4.38 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 7 8 18.76 $937.86 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 5 5 49.15 $1228.69 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 4 4 9.27 $680.35 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 43 43 100.71 $2517.74 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 166 182 977.29 $48864.32 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 4 4 21.79 $1089.52 $50.00
INTR -INTR INTERPRETER 6 6 70.29 $3514.29 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 1 1 1.00 $67.88 $67.88
OCCT -97530HM OT SESSION BY OT ASST 15 17 130.73 $7101.43 $54.32
PHY -97110 PT SESSION BY LICENSED PT 1 1 12.00 $814.56 $67.88
PHY -97110HM PT SESSION BY PT ASST 23 24 216.40 $11755.11 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 14 14 9.58 $9.58 $1.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 4 5.00 $325.00 $65.00
SENS -V5264 EARMOLD 3 5 3.71 $69.47 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 1.03 $51.67 $50.00
SPL -92508 GROUP SPL SESSION PER CHILD 25 26 332.56 $4389.76 $13.20
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Subtotal (Total Children Is Unduplicated) 219 378 2035.69 $89007.73 $43.72
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Total 514 2173.54 $100870.19 $46.41
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Number of Children (Unduplicated) With at Least One Authorization 285