Summary Report for FSPSAs Ending During the Report Period Center: 07
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 1 1 4.07 $150.47 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 1.02 $37.82 $37.00
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Subtotal (Total Children Is Unduplicated) 2 2 5.09 $188.29 $37.00
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.00 $16.30 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.00 $8.83 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.00 $10.80 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.00 $21.79 $21.79
AUDE -AUDE UNSPECIFIED AUDE SERVICES 6 6 6.00 $360.00 $60.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 6 7 108.71 $13589.31 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 12 12 15.01 $750.56 $50.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 2.81 $156.02 $55.50
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 2 2 3.50 $262.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 7 8 15.00 $832.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 121 176 285.13 $21385.01 $75.00
MED -MED UNSPECIFIED MED OFFICE VISIT 1 1 1.00 $150.00 $150.00
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 2 2 1.77 $88.34 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 3 3 3.00 $150.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 11 11 9.23 $447.82 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 79 83 77.88 $3777.34 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 15 15 18.97 $920.11 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 86 98 134.48 $6522.13 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 1 1 1.00 $50.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 191 216 206.08 $9994.77 $48.50
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Subtotal (Total Children Is Unduplicated) 394 649 896.58 $59680.19 $66.56
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 4.00 $6000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 5.00 $250.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 21 21 41.81 $2090.68 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 3 4 4.90 $122.50 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 21 23 39.73 $1986.67 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 12 13 27.43 $1371.67 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 3 5.82 $145.42 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 13 17 40.44 $2022.08 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 2 9.94 $248.54 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 13 16 32.19 $1609.58 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 6 7 13.78 $344.49 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 19 26 1825.71 $22821.43 $12.50
EIGF -T1024TTHN *EI GROUP SESSION BY PROF 1 1 3.29 $82.14 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 19.57 $489.29 $25.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 143 143 1115.62 $55781.06 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 52.71 $1317.86 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 414 533 8954.06 $447702.95 $50.00
HERN -T1024HN *EI HEARING SERVICES AFTER SHINE 4 4 82.29 $4114.29 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 15 15 239.74 $11986.90 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 70 86 1410.82 $95766.74 $67.88
OCCT -97530HM OT SESSION BY OT ASST 55 61 949.84 $51595.34 $54.32
PHY -97110 PT SESSION BY LICENSED PT 104 140 2580.56 $175168.26 $67.88
PHY -97110HM PT SESSION BY PT ASST 77 96 1492.10 $81051.11 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 6 6 5.80 $5.80 $1.00
SENS -V5264 EARMOLD 1 1 1.00 $18.72 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 2.00 $100.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 208 281 4370.72 $296684.15 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 4 4 35.00 $1901.20 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 123 152 2461.53 $32492.26 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 2 2 39.00 $19.50 $0.50
VISN -T1024HN *EI VISION SERVICES, INDIVIDUAL 3 3 29.00 $1450.00 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 4 43.21 $2160.72 $50.00
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Subtotal (Total Children Is Unduplicated) 794 1678 25938.63 $1298901.31 $50.08
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Total 2329 26840.30 $1358769.79 $50.62
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Number of Children (Unduplicated) With at Least One Authorization 905