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: 07/01/10 and 09/30/10 Date of Report: 11-17-10 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 -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 2.000000 $21.6000 $10.8000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 43 45 46.666667 $5366.6700 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 8 8 8.000000 $1000.0000 $125.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 14 14 15.000000 $832.5000 $55.5000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 1.000000 $50.0000 $50.0000
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 7 7 11.433333 $571.6700 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 9 9 10.285714 $498.8600 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 23 23 23.466667 $1138.1400 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 28 28 85.857143 $4164.0700 $48.5000
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Subtotal (Total Children Is Unduplicated) 94 138 204.709524 $13688.5000 $66.8700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 8 9.144445 $13716.7500 $1500.0100
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.700000 $121.7400 $71.6100
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 9.842857 $492.1500 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 2 2.000000 $100.0000 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 6 6 5.133334 $256.6700 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 5 5 3.759524 $93.9900 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 2 2 6.200000 $310.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 0.491667 $12.2900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 3.666667 $183.3400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 3 3 2.050000 $51.2500 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 10 10 11.333333 $566.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 2.575000 $64.3800 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 8 8 26.690477 $1959.6200 $73.4200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 35 35 109.566666 $2739.1700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 1.233333 $61.6700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 141 154 782.798411 $39139.9700 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 5 5 37.923810 $1896.2000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 12.000000 $814.5600 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 15 16 132.983333 $7223.6600 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 2 2 14.428571 $979.4100 $67.8800
PHY -97110HM PT SESSION BY PT ASST 22 23 165.880951 $9010.6600 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 11 11 8.544445 $8.5400 $1.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.000000 $65.0000 $65.0000
SENS -V5264 EARMOLD 4 4 5.555555 $100.0000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 5 5 20.080953 $1004.0500 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 8.571429 $581.8300 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 31 34 231.142854 $3051.0900 $13.2000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 1.000000 $50.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 205 351 1617.297615 $84654.6200 $52.3400
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Total 489 1822.007139 $98343.1200 $53.9800
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Number of Children (Unduplicated) With at Least One Authorization 225