Summary Report for FSPSAs Initiated During the Report Period Center: 55
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
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 5 7 7.00 $420.00 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.00 $119.60 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 6.14 $767.86 $125.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 36 45 44.07 $2137.24 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 65 71 71.00 $3443.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 22 27 27.00 $1309.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 59 62 61.86 $3000.26 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 169 197 199.21 $9661.67 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 6.00 $600.00 $100.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 221 412 423.28 $21459.63 $50.70
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 6 6.00 $9000.00 $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 3 3 12.82 $641.19 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 4 4 12.62 $631.19 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 3.27 $163.34 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 4 5 16.81 $840.71 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 2 4 14.95 $373.69 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 148.57 $3714.29 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 6 6 156.43 $7821.43 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 1 1 5.86 $292.86 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 67 95 1538.84 $76941.91 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 1.00 $50.00 $50.00
INTR -INTR INTERPRETER 1 2 12.14 $607.14 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 176 251 4440.43 $301416.33 $67.88
OCCT -97530HM OT SESSION BY OT ASST 3 4 66.07 $3589.00 $54.32
PHY -97110 PT SESSION BY LICENSED PT 101 145 2455.27 $166663.99 $67.88
PHY -97110HM PT SESSION BY PT ASST 8 9 67.16 $3647.89 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 0.17 $0.17 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 270 361 5989.21 $406547.46 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 17 17 152.36 $2011.11 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 130 200 13321.44 $6660.72 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 2 27.43 $1371.43 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 365 1133 28483.70 $994728.68 $34.92
-----------------------------------------------------------------------------------------------------------------------------
Total 1545 28906.98 $1016188.31 $35.15
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 394