Summary Report for FSPSAs Ending During the Report Period Center: 57
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 18 18 10.97 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 9 11 8.50 $314.50 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 1.00 $37.00 $37.00
TCON -TCON TRANSITION CONFERENCE 4 4 4.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 26 34 24.47 $351.50 $14.36
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 30 31 31.02 $1861.33 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 6 6.00 $717.60 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 4 4 4.00 $500.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 10 11 11.02 $1377.78 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.00 $50.00 $50.00
FANE -FANE FAMILY INTERVIEW BY COMMUNITY PROVI 4 4 4.00 $120.00 $30.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 0.06 $4.58 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 0.27 $20.42 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 3.00 $166.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 4 4 5.00 $375.00 $75.00
MED -MED UNSPECIFIED MED OFFICE VISIT 1 1 1.00 $150.00 $150.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 24 27 32.43 $1572.79 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 43 47 46.25 $2243.23 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 1 1 1.00 $50.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 115 123 153.99 $7468.51 $48.50
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Subtotal (Total Children Is Unduplicated) 200 266 301.05 $16713.79 $55.52
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 4 4 4.00 $200.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 4 4 25.89 $1294.29 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 3 3 11.67 $291.67 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 202 240 1141.91 $57095.26 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 68 77 359.14 $8978.58 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 7 7 58.30 $2914.76 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 10 10 59.53 $2976.67 $50.00
CONPP -CONPP CONSULT, PT, PHONE 3 3 7.97 $199.17 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 267 339 1662.89 $83144.41 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 78 93 378.56 $9463.94 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 18 20 213.80 $15697.08 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 3 3 746.71 $9333.93 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 8 8 60.00 $1500.00 $25.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 66 67 485.43 $24271.41 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 410 569 10097.22 $504860.92 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 46 52 509.29 $34570.33 $67.88
OCCT -97530HM OT SESSION BY OT ASST 29 33 327.74 $17802.73 $54.32
PHY -97110 PT SESSION BY LICENSED PT 106 117 1194.82 $81104.37 $67.88
PHY -97110HM PT SESSION BY PT ASST 36 36 436.14 $23691.28 $54.32
SHIN -T1024HN *INITIAL SHINE SERVICES, INDIVIDUAL 1 1 11.43 $571.43 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 11 13 204.55 $10227.62 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 140 159 1300.24 $88260.53 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 27.29 $1482.16 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 38 41 340.29 $4491.77 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 16.00 $1600.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 445 805 12304.21 $6152.10 $0.50
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Subtotal (Total Children Is Unduplicated) 573 2707 31985.00 $992176.38 $31.02
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Total 3007 32310.52 $1009241.67 $31.24
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Number of Children (Unduplicated) With at Least One Authorization 584