Summary Report for FSPSAs Ending During the Report Period Center: 04
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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 2 2 2.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 2 2 2.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 44 69 95.86 $4649.07 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 1 2 2.00 $72.14 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.00 $60.00 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 5.00 $598.00 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 308 424 483.53 $24176.43 $50.00
MED -MED UNSPECIFIED MED OFFICE VISIT 1 1 1.00 $150.00 $150.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 3 3 3.00 $150.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 2 2 2.00 $97.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 221 290 323.29 $15679.58 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 2.00 $97.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 216 280 343.54 $16661.83 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 291 371 409.41 $19856.59 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 4 5 40.86 $2042.86 $50.00
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Subtotal (Total Children Is Unduplicated) 750 1455 1712.49 $84290.50 $49.22
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 38 39 44.10 $2205.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 543 922 3853.57 $192678.45 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 16 16 173.80 $4345.12 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 243 391 1573.33 $78666.26 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 27.29 $682.14 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 149 245 1000.91 $50045.44 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 20.57 $514.29 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 325 512 1944.67 $97233.72 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 14 14 148.30 $3707.62 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 6 6 28.86 $2118.69 $73.42
EIGF -T1024TTHN *EI GROUP SESSION BY PROF 15 15 132.84 $3320.99 $25.00
EIGF -T1027TTHM EI GROUP SESSION BY PARAPROF 2 2 15.00 $187.50 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 236 396 2998.29 $74957.31 $25.00
EIIF -90846 FAMILY PSYCHOTHERAPY W/O PATIENT 1 1 7.71 $385.72 $50.00
EIIF -90847 FAMILY PSYCHOTHERAPY WITH PATIENT 1 1 8.29 $414.29 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 145 152 1354.71 $67735.27 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 4 4 63.29 $1582.15 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 759 1359 25949.57 $1297478.49 $50.00
INTR -INTR INTERPRETER 1 1 0.50 $25.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 313 566 4235.27 $287490.02 $67.88
PHY -97110 PT SESSION BY LICENSED PT 351 643 5386.58 $365641.16 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 24 27 46.09 $46.09 $1.00
SENS -V5264 EARMOLD 1 1 1.00 $18.72 $18.72
SHIN -T1024HN *INITIAL SHINE SERVICES, INDIVIDUAL 2 2 10.85 $542.38 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 20 36 186.45 $9322.63 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 412 670 4890.14 $331942.51 $67.88
TRAN -TRAN FAMILY TRANSPORTATION 6 6 40.43 $4042.87 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 688 1283 7587.68 $3793.83 $0.50
VISN -T1024HN *EI VISION SERVICES, INDIVIDUAL 2 2 2.80 $139.77 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 17 27 193.90 $9695.24 $50.00
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Subtotal (Total Children Is Unduplicated) 1129 7342 61926.78 $2890958.63 $46.68
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Total 8799 63641.27 $2975249.13 $46.75
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Number of Children (Unduplicated) With at Least One Authorization 1195