Summary Report for FSPSAs Initiated During the Report Period Center: 53
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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1 3.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 1 1 3.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 3 3 3.00 $145.50 $48.50
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 0.27 $16.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 72 72 83.18 $9948.06 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 9 11 15.00 $1875.00 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 2 2 2.00 $100.00 $50.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 8 8 10.00 $555.00 $55.50
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 2 2 1.67 $83.34 $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 21 22 22.00 $1067.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 48 48 48.00 $2328.00 $48.50
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Subtotal (Total Children Is Unduplicated) 122 179 195.11 $16601.20 $85.09
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 1.93 $2899.95 $1500.00
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.00 $68.86 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 6 6 22.98 $1148.81 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 2 2.00 $100.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 3 3 4.83 $241.67 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 3 3 4.30 $215.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 9 9 14.73 $736.67 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 9.71 $242.86 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 8 8 12.77 $937.33 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 24 24 59.50 $1487.38 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 6.86 $342.86 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 167 172 880.02 $44001.13 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 4 4 31.14 $1557.15 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 1 1 12.00 $814.56 $67.88
OCCT -97530HM OT SESSION BY OT ASST 16 17 124.13 $6742.67 $54.32
PHY -97110 PT SESSION BY LICENSED PT 1 1 24.00 $1629.12 $67.88
PHY -97110HM PT SESSION BY PT ASST 18 18 137.30 $7458.15 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 14 14 9.60 $9.60 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 3.00 $195.00 $65.00
SENS -V5264 EARMOLD 3 3 7.02 $131.46 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 5 5 12.79 $639.29 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 24.00 $1629.12 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 23 23 233.08 $3076.60 $13.20
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Subtotal (Total Children Is Unduplicated) 216 322 1640.69 $77305.22 $47.12
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Total 502 1838.80 $93906.42 $51.07
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Number of Children (Unduplicated) With at Least One Authorization 242