Summary Report for FSPSAs Ending During the Report Period Center: 54
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 3 3 3.00 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 3 3 58.00 $2146.00 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 7.43 $274.86 $37.00
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Subtotal (Total Children Is Unduplicated) 6 7 68.43 $2420.86 $35.38
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 1.00 $48.50 $48.50
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 2 3 3.00 $163.14 $54.38
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.00 $31.81 $31.81
AUDE -AUDE UNSPECIFIED AUDE SERVICES 109 121 134.25 $8055.14 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 1.73 $81.12 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 39 42 41.73 $4991.30 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 4 4 4.00 $500.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 10 11 26.43 $3303.58 $125.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 1.00 $75.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.00 $75.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 1.00 $55.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 1.00 $75.00 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 24 26 38.14 $1849.93 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 115 129 146.14 $7087.93 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 21 21 34.29 $1662.86 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 65 67 82.71 $4011.64 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 205 235 252.29 $12235.86 $48.50
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Subtotal (Total Children Is Unduplicated) 358 667 770.72 $44303.31 $57.48
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.00 $68.86 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 12 14 76.20 $3810.09 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 8 9 64.14 $3207.15 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 5 6 18.20 $455.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 114 149 656.01 $32800.37 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 27 30 97.64 $2441.11 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 73 97 285.64 $14281.84 $50.00
CONOP -CONOP CONSULT, OT, PHONE 18 21 64.58 $1614.59 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 25 35 145.82 $7290.78 $50.00
CONPP -CONPP CONSULT, PT, PHONE 11 13 42.17 $1054.16 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 97 129 452.31 $22615.43 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 26 27 77.95 $1948.81 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 9.36 $687.00 $73.42
EIGF -T1024TTHN *EI GROUP SESSION BY PROF 1 1 13.00 $325.00 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 18.86 $942.86 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 50 54 430.87 $21543.56 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 5.71 $142.86 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 276 382 6749.00 $337450.06 $50.00
INTR -INTR INTERPRETER 20 37 373.90 $18694.99 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 198 273 4883.02 $331459.66 $67.88
OCCT -97530HM OT SESSION BY OT ASST 35 42 722.12 $39225.38 $54.32
PHY -97110 PT SESSION BY LICENSED PT 141 193 2954.03 $200519.26 $67.88
PHY -97110HM PT SESSION BY PT ASST 26 29 416.70 $22635.13 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 1.00 $1.00 $1.00
SENS -FM FM RECEIVER HEARING AID 2 2 2.00 $3300.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 2 1.03 $245.02 $237.12
SENS -V5264 EARMOLD 7 8 41.72 $781.04 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 7 8 79.54 $3976.91 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 225 331 4606.34 $312678.36 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 4 4 22.57 $1226.08 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 32 37 576.14 $7605.09 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 2.00 $200.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 418 869 182054.92 $91027.45 $0.50
VISN -T1024HN *EI VISION SERVICES, INDIVIDUAL 1 1 2.29 $114.29 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 5 6 123.00 $6150.00 $50.00
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Subtotal (Total Children Is Unduplicated) 593 2818 206073.78 $1495019.15 $7.25
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Total 3492 206912.93 $1541743.32 $7.45
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Number of Children (Unduplicated) With at Least One Authorization 636