Summary Report for FSPSAs Ending During the Report Period Center: 51
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
TCM -T1017TL TARGETED CASE MANAGEMENT 7 7 35.87 $1327.06 $37.00
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Subtotal (Total Children Is Unduplicated) 7 7 35.87 $1327.06 $37.00
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 14 14 18.17 $1089.99 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 3.00 $358.80 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 3 3 3.00 $375.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 13 13 25.34 $1267.15 $50.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 1.00 $75.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 4.00 $222.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 26 26 31.14 $2335.72 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 10 10 14.00 $1050.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 14 14 21.00 $1575.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 7 8 12.00 $666.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 47 49 66.14 $4960.72 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 3 3 3.00 $145.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 29 29 123.57 $5993.21 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 11 12 11.52 $558.83 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 19 21 21.00 $1018.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 50 54 115.57 $5605.21 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 9 12 15.57 $778.57 $50.00
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Subtotal (Total Children Is Unduplicated) 161 277 493.03 $28308.07 $57.42
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.00 $3000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 8 9 56.09 $2804.52 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 2 3.00 $150.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 149 219 538.93 $26946.63 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 86 118 228.36 $11418.13 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 3 3.41 $85.27 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 84 113 272.40 $13619.92 $50.00
CONPP -CONPP CONSULT, PT, PHONE 5 5 15.83 $395.63 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 85 104 170.13 $8506.65 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 4 5 36.57 $2685.08 $73.42
EIGF -T1024TTHN *EI GROUP SESSION BY PROF 3 3 138.00 $3450.00 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 11 14 1191.86 $29796.43 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 160.00 $8000.00 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 51 51 274.85 $13742.39 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 3 3 44.71 $1117.86 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 217 293 5828.99 $291449.72 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 4 54.99 $2749.53 $50.00
INTR -INTR INTERPRETER 1 1 26.14 $1307.15 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 168 246 4951.44 $336103.77 $67.88
OCCT -97530HM OT SESSION BY OT ASST 14 14 330.39 $17946.82 $54.32
PHY -97110 PT SESSION BY LICENSED PT 162 239 5175.18 $351291.07 $67.88
PHY -97110HM PT SESSION BY PT ASST 13 14 285.02 $15482.23 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 1.00 $1.00 $1.00
SENS -V5264 EARMOLD 2 2 3.04 $56.99 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 8 9 103.31 $5165.73 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 233 328 5910.88 $401230.61 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 15 15 236.00 $3115.20 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 57 87 115320.79 $57660.39 $0.50
VISN -T1024HN *EI VISION SERVICES, INDIVIDUAL 2 2 9.57 $478.34 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 5 5 13.97 $698.34 $50.00
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Subtotal (Total Children Is Unduplicated) 459 1912 141386.86 $1610455.35 $11.39
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Total 2196 141915.76 $1640090.48 $11.56
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Number of Children (Unduplicated) With at Least One Authorization 504