Summary Report for FSPSAs Initiated During the Report Period Center: 54
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 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 2 2.00 $108.76 $54.38
AUDE -AUDE UNSPECIFIED AUDE SERVICES 134 150 161.60 $9695.81 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 2.73 $127.92 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 46 48 47.73 $5708.90 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 4 4 4.00 $500.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 13 13 28.43 $3553.58 $125.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 2 2.00 $150.00 $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 42.08 $2040.70 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 108 122 140.43 $6810.79 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 25 26 39.29 $1905.36 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 68 69 86.14 $4177.93 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 231 263 268.00 $12998.00 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 1.00 $100.00 $100.00
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Subtotal (Total Children Is Unduplicated) 404 733 829.43 $48131.74 $58.03
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 14 15 75.13 $3756.52 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 12 13 72.61 $3630.48 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 6 7 17.33 $433.33 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 172 218 841.30 $42064.77 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 20 21 72.73 $1818.19 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 89 119 341.98 $17098.86 $50.00
CONOP -CONOP CONSULT, OT, PHONE 13 14 49.78 $1244.58 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 38 49 175.33 $8766.60 $50.00
CONPP -CONPP CONSULT, PT, PHONE 9 10 34.67 $866.67 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 149 188 568.95 $28447.33 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 18 19 59.44 $1485.90 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 9.36 $687.00 $73.42
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 18.86 $942.86 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 1.00 $50.00 $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 377 541 8191.82 $409591.23 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 2.33 $116.67 $50.00
INTR -INTR INTERPRETER 30 48 452.86 $22643.21 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 185 258 4201.01 $285164.85 $67.88
OCCT -97530HM OT SESSION BY OT ASST 28 33 536.05 $29117.97 $54.32
PHY -97110 PT SESSION BY LICENSED PT 131 188 2484.66 $168658.90 $67.88
PHY -97110HM PT SESSION BY PT ASST 16 17 259.16 $14077.41 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 16 16 16.00 $16.00 $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 -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.00 $65.00 $65.00
SENS -V5264 EARMOLD 7 8 37.10 $694.51 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 8 9 81.87 $4093.58 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 255 366 4788.90 $325070.46 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 8.57 $465.60 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 31 32 429.75 $5672.70 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 2.00 $200.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 526 1073 249306.73 $124653.36 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 6 8 151.29 $7564.28 $50.00
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Subtotal (Total Children Is Unduplicated) 677 3282 273299.27 $1513601.65 $5.54
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Total 4022 274197.13 $1564154.24 $5.70
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Number of Children (Unduplicated) With at Least One Authorization 701