Summary Report for FSPSAs Initiated During the Report Period Center: 51
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
TCM -T1017TL TARGETED CASE MANAGEMENT 4 4 24.03 $889.23 $37.00
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Subtotal (Total Children Is Unduplicated) 4 4 24.03 $889.23 $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 15 17 20.16 $1209.32 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.98 $236.54 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 5 5 5.00 $625.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 13 14 39.57 $1978.58 $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 2 2 2.00 $97.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 21 21 92.00 $4462.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 5 5 5.00 $242.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 21 22 22.00 $1067.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 55 60 238.71 $11577.64 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 9 11 13.00 $650.00 $50.00
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Subtotal (Total Children Is Unduplicated) 155 270 591.70 $33216.09 $56.14
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.00 $3000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 8 9 57.56 $2878.10 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 1.00 $50.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 157 203 540.08 $27003.95 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 90 117 230.38 $11519.23 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 3.13 $78.13 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 90 115 269.25 $13462.42 $50.00
CONPP -CONPP CONSULT, PT, PHONE 5 5 15.83 $395.63 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 114 136 228.64 $11431.99 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 5 6 36.43 $2674.59 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 8 9 747.86 $18696.43 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 208.29 $10414.29 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 39.71 $992.86 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 224 283 5940.00 $297000.13 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 3 5 57.41 $2870.48 $50.00
INTR -INTR INTERPRETER 1 1 26.14 $1307.15 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 154 215 4477.87 $303957.90 $67.88
OCCT -97530HM OT SESSION BY OT ASST 12 12 259.00 $14068.62 $54.32
PHY -97110 PT SESSION BY LICENSED PT 152 218 4875.21 $330928.97 $67.88
PHY -97110HM PT SESSION BY PT ASST 12 13 302.88 $16452.24 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 3 3 3.00 $3.00 $1.00
SENS -V5264 EARMOLD 1 1 1.98 $37.02 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 6 8 69.18 $3458.82 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 235 316 5973.21 $405461.35 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 8 8 155.93 $2058.26 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 51 75 97063.64 $48531.82 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 8 8 79.50 $3974.77 $50.00
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Subtotal (Total Children Is Unduplicated) 436 1775 121665.08 $1532708.10 $12.60
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Total 2049 122280.82 $1566813.42 $12.81
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Number of Children (Unduplicated) With at Least One Authorization 470