Summary Report for FSPSAs Ending During the Report Period Center: 54
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: 07/01/08 and 09/30/08 Date of Report: 11-18-08 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 1.00 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 11.43 $422.86 $37.00
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Subtotal (Total Children Is Unduplicated) 2 3 12.43 $422.86 $34.02
Screening, Eval, and Assessment, Class # 02
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.00 $54.38 $54.38
AUDE -AUDE UNSPECIFIED AUDE SERVICES 27 27 26.54 $1592.47 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 8 8 8.00 $956.80 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 1.00 $125.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 4 4 4.00 $500.00 $125.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 6 6 6.00 $291.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 27 28 34.43 $1669.79 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 5 5 5.00 $242.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 15 15 15.00 $727.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 53 53 53.00 $2570.50 $48.50
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Subtotal (Total Children Is Unduplicated) 102 148 153.97 $8729.94 $56.70
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 7.07 $353.34 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 2.40 $120.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.17 $4.17 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 34 40 50.75 $2537.63 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 6 6 9.18 $229.58 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 19 20 24.33 $1216.67 $50.00
CONOP -CONOP CONSULT, OT, PHONE 5 5 3.35 $83.75 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 8 10 17.46 $873.22 $50.00
CONPP -CONPP CONSULT, PT, PHONE 3 3 1.92 $47.92 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 29 37 35.83 $1791.56 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 6 6 5.70 $142.50 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 6.50 $477.23 $73.42
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 8.00 $400.00 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 101 116 771.13 $38556.45 $50.00
INTR -INTR INTERPRETER 9 11 36.51 $1825.72 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 46 51 293.02 $19889.99 $67.88
OCCT -97530HM OT SESSION BY OT ASST 7 7 26.29 $1428.10 $54.32
PHY -97110 PT SESSION BY LICENSED PT 38 40 222.28 $15088.69 $67.88
PHY -97110HM PT SESSION BY PT ASST 4 4 18.39 $999.10 $54.32
SENS -FM FM RECEIVER HEARING AID 1 1 1.00 $1650.00 $1650.00
SENS -V5264 EARMOLD 3 3 2.00 $37.44 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 4 4 13.03 $651.67 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 75 86 427.75 $29035.69 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 21.39 $282.38 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 147 210 13485.75 $6742.88 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 1.00 $50.00 $50.00
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Subtotal (Total Children Is Unduplicated) 209 673 15492.22 $124515.65 $8.04
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Total 824 15658.62 $133668.44 $8.54
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Number of Children (Unduplicated) With at Least One Authorization 243