Summary Report for FSPSAs Ending During the Report Period Center: 52
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 1 1 1.00 $0.00 $0.00
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 2.79 $103.07 $37.00
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Subtotal (Total Children Is Unduplicated) 2 2 3.79 $103.07 $27.23
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 7 7 7.00 $420.00 $60.00
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
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 4 4 4.00 $500.00 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 16 21 21.00 $1050.00 $50.00
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 106 139 140.00 $6790.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 41 51 51.00 $2473.50 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 16 16 16.00 $800.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 113 133 133.00 $6450.50 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.00 $50.00 $50.00
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Subtotal (Total Children Is Unduplicated) 226 376 378.00 $18917.00 $50.04
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 8 13 16.00 $24000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 6 8 12.83 $641.67 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 3.05 $152.50 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 83 117 348.75 $17437.52 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 47 65 164.90 $8245.13 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.30 $32.50 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 41 64 185.20 $9259.88 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 83 119 319.37 $15968.34 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.30 $32.50 $25.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 29 29 284.34 $14216.90 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 2 48.00 $1200.00 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 196 355 4131.03 $206551.43 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 26.14 $1307.15 $50.00
INTR -INTR INTERPRETER 1 1 2.00 $100.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 119 195 2363.79 $160453.88 $67.88
PHY -97110 PT SESSION BY LICENSED PT 132 237 2682.72 $182102.88 $67.88
PHY -97110HM PT SESSION BY PT ASST 2 2 4.37 $237.32 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 2 2 1.82 $1.82 $1.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 1 1 2.00 $37.44 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 2.43 $121.43 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 281 479 4439.27 $301337.51 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 18 21 252.50 $3333.00 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 297 642 619211.64 $309605.82 $0.50
VISN -T1024HN *EI VISION SERVICES, INDIVIDUAL 2 2 24.82 $1241.08 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 6 29.00 $1450.00 $50.00
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Subtotal (Total Children Is Unduplicated) 452 2366 634560.57 $1259541.93 $1.98
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Total 2744 634942.35 $1278562.00 $2.01
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Number of Children (Unduplicated) With at Least One Authorization 473