Summary Report for FSPSAs Initiated During the Report Period Center: 52
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
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
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 2.00 $72.14 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 5 5 5.00 $300.00 $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 7 7 8.00 $1000.00 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 17 22 22.00 $1100.00 $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 111 144 145.00 $7032.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 2.00 $97.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 47 56 56.00 $2716.00 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 18 18 18.00 $900.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 124 150 151.90 $7367.15 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 2 2 2.00 $100.00 $50.00
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Subtotal (Total Children Is Unduplicated) 244 411 416.90 $21067.79 $50.53
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 9 14 17.00 $25500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 4 7 12.03 $601.67 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 2 3.52 $175.84 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 93 131 386.46 $19323.21 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 55 68 175.39 $8769.30 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.30 $32.50 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 51 67 213.81 $10690.47 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 94 128 354.38 $17718.75 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.30 $32.50 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 11.43 $571.43 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 3 50.43 $1260.72 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 213 405 4417.24 $220861.79 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 2 42.29 $2114.29 $50.00
INTR -INTR INTERPRETER 1 1 2.00 $100.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 127 208 2572.58 $174626.59 $67.88
PHY -97110 PT SESSION BY LICENSED PT 128 231 2851.78 $193579.00 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 3.08 $167.48 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 5 5 4.61 $4.61 $1.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 1 3 6.00 $112.32 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 14.43 $721.43 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 302 511 4797.83 $325676.67 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 10 13 230.50 $3042.60 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 386 952 850095.29 $425047.64 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 8 12 49.43 $2471.43 $50.00
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Subtotal (Total Children Is Unduplicated) 483 2770 866316.09 $1433676.47 $1.65
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Total 3183 866736.78 $1454847.33 $1.68
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Number of Children (Unduplicated) With at Least One Authorization 497