Summary Report for FSPSAs Initiated During the Report Period Center: 04
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: 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 1 1 1.00 $0.00 $0.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 1 1 1.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 40 61 88.86 $4309.57 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.00 $239.20 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 231 294 409.10 $20455.00 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 3 3 3.00 $150.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 284 380 455.21 $22077.66 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 239 333 406.33 $19706.94 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 363 474 570.94 $27690.49 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 25.71 $1285.72 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 803 1549 1963.15 $95997.44 $48.90
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 22 23 30.10 $1505.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 472 747 3226.24 $161312.19 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 204 322 1359.09 $67954.59 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 120 197 903.89 $45194.50 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 297 421 1646.79 $82339.36 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 2 2 12.13 $303.33 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 10 10 32.25 $2367.50 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 232 385 3161.40 $79034.97 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 40.00 $1000.00 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 916 1541 24803.93 $1240196.34 $50.00
INTR -INTR INTERPRETER 1 1 0.50 $25.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 394 650 5260.41 $357076.29 $67.88
PHY -97110 PT SESSION BY LICENSED PT 386 687 6538.26 $443817.31 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 43 55 75.33 $75.33 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 4.00 $2000.00 $500.00
SENS -V5264 EARMOLD 3 3 3.36 $62.82 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 26 41 215.87 $10793.58 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 500 754 5845.08 $396763.79 $67.88
TRAN -TRAN FAMILY TRANSPORTATION 4 4 25.00 $2500.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 776 1320 7298.75 $3649.37 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 17 31 258.57 $12928.34 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 1255 7198 60740.94 $2910899.59 $47.92
-----------------------------------------------------------------------------------------------------------------------------
Total 8748 62705.09 $3006897.04 $47.95
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 1304