Summary Report for FSPSAs Ending During the Report Period Center: 55
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
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 5 6 6.00 $360.00 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 13 13 13.00 $1554.80 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 36 42 42.00 $2037.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 65 73 73.00 $3540.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 24 28 28.00 $1358.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 58 66 66.00 $3201.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 152 181 181.00 $8778.50 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 1.00 $100.00 $100.00
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Subtotal (Total Children Is Unduplicated) 209 411 411.00 $21054.80 $51.23
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 9 9 12.00 $18000.00 $1500.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 12 12 34.86 $1742.86 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 2 2 7.96 $397.86 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 5 5 20.47 $1023.45 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 3 5 18.70 $935.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 7 9 33.36 $1667.97 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 2 4 14.95 $373.69 $25.00
EIGF -T1024TTHN *EI GROUP SESSION BY PROF 1 1 435.43 $10885.72 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 148.57 $3714.29 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 15.00 $750.00 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 5 5 134.43 $6721.43 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 9 10 79.86 $3992.86 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 56 76 1407.50 $70374.99 $50.00
HERN -T1024HN *EI HEARING SERVICES AFTER SHINE 1 1 11.29 $564.29 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 1.00 $50.00 $50.00
INTR -INTR INTERPRETER 1 1 4.57 $228.57 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 191 281 4748.05 $322297.96 $67.88
OCCT -97530HM OT SESSION BY OT ASST 5 5 77.43 $4205.92 $54.32
PHY -97110 PT SESSION BY LICENSED PT 104 146 2286.50 $155207.29 $67.88
PHY -97110HM PT SESSION BY PT ASST 4 4 26.64 $1447.24 $54.32
SENS -V5264 EARMOLD 1 1 1.00 $18.72 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 262 369 5690.81 $386292.01 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 12 12 146.21 $1930.03 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 66 97 7095.89 $3547.94 $0.50
VISN -T1024HN *EI VISION SERVICES, INDIVIDUAL 1 1 11.29 $564.29 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 27.43 $1371.43 $50.00
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Subtotal (Total Children Is Unduplicated) 346 1063 22491.18 $998305.76 $44.39
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Total 1474 22902.18 $1019360.56 $44.51
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Number of Children (Unduplicated) With at Least One Authorization 363