Summary Report for FSPSAs Ending During the Report Period Center: 01
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: 01/01/08 and 12/31/08 Date of Report: 02-16-09 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
CASE -CASE NON-TCM CASE MANAGEMENT 2 2 0.29 $10.57 $37.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 1.00 $37.00 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 3 3 1.96 $72.68 $37.00
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Subtotal (Total Children Is Unduplicated) 4 6 3.25 $120.25 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 27 34 35.00 $1697.50 $48.50
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 2 2 2.00 $108.76 $54.38
AUDE -AUDE UNSPECIFIED AUDE SERVICES 43 45 50.88 $3052.66 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 4 5.29 $247.52 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 22 22 30.00 $3588.00 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 15 16 18.00 $900.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 70 71 99.68 $4983.93 $50.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 10 10 14.50 $1087.50 $75.00
IPDEF -IPDEF_NM F/U PSYCH & DEV EVAL BY NON-MED PRO 1 1 1.50 $83.25 $55.50
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 47 47 61.91 $4643.34 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.00 $75.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 10 10 17.00 $1275.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 57 59 76.00 $5700.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 97 101 134.91 $7487.57 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 3 3 4.00 $222.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 544 549 752.57 $56442.86 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 36 36 41.50 $3112.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 127 128 205.14 $15385.72 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 606 615 845.07 $46901.47 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 653 703 962.00 $72150.01 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 29 31 104.71 $5078.64 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 58 61 94.71 $4593.64 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 50 53 94.71 $4593.64 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 73 76 131.00 $6353.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 202 216 302.36 $14664.37 $48.50
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Subtotal (Total Children Is Unduplicated) 1396 2894 4085.45 $264428.38 $64.72
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 52 81 90.00 $135000.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.00 $68.86 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 16 16 18.77 $938.34 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 120 128 176.39 $8819.41 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 22 27 60.97 $1524.28 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 27 29 55.20 $2760.01 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 12 13 54.25 $1356.31 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 4 4 9.70 $485.00 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 3 1.50 $37.50 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 8 9 14.87 $743.34 $50.00
CONPP -CONPP CONSULT, PT, PHONE 8 9 17.92 $447.92 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 27 29 95.92 $4796.03 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 27 28 89.39 $2234.70 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 105.71 $1321.43 $12.50
EIGF -T1024TTHN *EI GROUP SESSION BY PROF 8 9 186.14 $4653.57 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 42 54 1111.43 $27785.71 $25.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 121 123 1066.48 $53324.03 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 434 538 9015.80 $450790.06 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 2 39.29 $1964.29 $50.00
INTR -INTR INTERPRETER 23 30 970.83 $48541.32 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 147 206 3430.34 $232851.21 $67.88
OCCT -97530HM OT SESSION BY OT ASST 35 37 566.78 $30787.55 $54.32
PHY -97110 PT SESSION BY LICENSED PT 247 361 6784.40 $460524.81 $67.88
PHY -97110HM PT SESSION BY PT ASST 49 51 848.95 $46115.11 $54.32
RSPT -RSPT RESPITE 1 1 103.47 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 15 15 674.89 $674.89 $1.00
SENS -FM FM RECEIVER HEARING AID 1 1 1.00 $1650.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 4.00 $2000.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 1.00 $237.12 $237.12
SENS -V5264 EARMOLD 6 9 15.00 $280.80 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 31.14 $1557.15 $50.00
SIC -SIC SPECIAL INSTRUCTION CONSULTATION 1 1 22.29 $1114.29 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 597 844 14429.24 $979456.76 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 19 19 200.00 $10863.99 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 49 53 974.07 $12857.74 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 30.14 $3014.29 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 991 1929 26083.43 $13041.71 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 2 145.14 $7257.14 $50.00
VISN -T1024HN *EI VISION SERVICES, INDIVIDUAL 4 4 100.86 $5042.86 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 5 7 152.00 $7600.00 $50.00
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Subtotal (Total Children Is Unduplicated) 1181 4680 67779.69 $2564519.50 $37.84
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Total 7580 71868.39 $2829068.14 $39.36
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Number of Children (Unduplicated) With at Least One Authorization 1688