Summary Report for FSPSAs Ending During the Report Period Center: 09
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 526 545 798.43 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 526 545 798.43 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 4 4 4.00 $194.00 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 3.39 $122.24 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 0.16 $9.33 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 3 3.00 $140.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.00 $239.20 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 5 5 5.00 $250.00 $50.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 3.00 $166.50 $55.50
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 37 39 40.00 $1940.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 22 22 22.00 $1067.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 15 16 16.00 $776.00 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.00 $50.00 $50.00
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Subtotal (Total Children Is Unduplicated) 82 101 102.54 $5100.17 $49.74
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 7 7.00 $10500.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 2 3.51 $241.77 $68.86
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.93 $64.27 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 8 9 100.57 $5028.57 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 13 15 22.13 $1106.67 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 28 37 65.93 $3296.67 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.00 $25.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 12 16 16.00 $800.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 38 44 77.49 $3874.52 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 14 15 118.93 $8731.74 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 1.00 $25.00 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 3 12.00 $600.00 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 3 3 21.00 $1050.00 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 49 50 774.25 $38712.62 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 280 414 5565.92 $278295.79 $50.00
HERN -T1024HN *EI HEARING SERVICES AFTER SHINE 1 1 1.00 $50.00 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 1.00 $50.00 $50.00
INTR -INTR INTERPRETER 2 3 4.00 $200.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 382 677 8033.21 $545294.20 $67.88
OCCT -97530HM OT SESSION BY OT ASST 7 8 108.35 $5885.70 $54.32
PHY -97110 PT SESSION BY LICENSED PT 401 674 9186.39 $623572.33 $67.88
PHY -97110HM PT SESSION BY PT ASST 4 4 22.43 $1218.32 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 1.00 $1.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 3 4.00 $2000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 6 6 3.97 $258.04 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 2.13 $505.85 $237.12
SENS -V5264 EARMOLD 9 10 33.15 $620.55 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 1.00 $50.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 679 1184 14342.64 $973578.31 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 3 3 41.14 $2234.88 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 19.29 $254.57 $13.20
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Subtotal (Total Children Is Unduplicated) 1001 3198 38592.37 $2508126.37 $64.99
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Total 3844 39493.34 $2513226.54 $63.64
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Number of Children (Unduplicated) With at Least One Authorization 1018