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: 10/01/08 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
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Subtotal (Total Children Is Unduplicated) 1 1 1.00 $0.00 $0.00
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 1 1 1.00 $60.00 $60.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 3 3 4.00 $500.00 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 2 3 3.00 $150.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 29 37 37.00 $1794.50 $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 9 10 10.00 $485.00 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 3 3 3.00 $150.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 38 44 45.90 $2226.15 $48.50
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Subtotal (Total Children Is Unduplicated) 80 105 108.90 $5583.29 $51.27
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 1 2 3.20 $160.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 0.47 $23.34 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 37 44 69.33 $3466.67 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 18 18 23.00 $1150.01 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 16 18 26.38 $1319.17 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 37 42 64.44 $3222.09 $50.00
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 1 2.43 $60.72 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 80 95 467.21 $23360.36 $50.00
INTR -INTR INTERPRETER 1 1 2.00 $100.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 50 54 332.92 $22598.91 $67.88
PHY -97110 PT SESSION BY LICENSED PT 45 47 229.98 $15610.87 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 5 5 4.61 $4.61 $1.00
SENS -V5264 EARMOLD 1 2 4.00 $74.88 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 12.00 $600.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 124 141 585.60 $39750.53 $67.88
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 170 235 92675.43 $46337.71 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 4 4.00 $200.00 $50.00
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Subtotal (Total Children Is Unduplicated) 224 713 94519.43 $160111.29 $1.69
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Total 819 94629.33 $165694.58 $1.75
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Number of Children (Unduplicated) With at Least One Authorization 237