Summary Report for FSPSAs Ending During the Report Period Center: 52
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: 04/01/09 and 06/30/09 Date of Report: 08-25-09 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
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 2.00 $72.14 $36.07
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.69 $201.99 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 4 5 6.00 $750.00 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 3 3 3.00 $150.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 39 49 49.00 $2376.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 16 16 16.00 $776.00 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 17 19 19.00 $950.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 48 49 49.00 $2376.50 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.00 $50.00 $50.00
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Subtotal (Total Children Is Unduplicated) 111 146 148.69 $7798.43 $52.45
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 2 3 13.50 $675.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 2.63 $131.67 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 45 49 57.38 $2869.17 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 24 26 29.97 $1498.33 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 19 21 24.40 $1220.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 49 54 64.37 $3218.74 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 0.14 $7.15 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 8.00 $200.00 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 93 109 501.86 $25093.03 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 4.43 $221.43 $50.00
INTR -INTR INTERPRETER 1 1 3.00 $150.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 46 48 265.94 $18052.05 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 2.86 $155.20 $54.32
PHY -97110 PT SESSION BY LICENSED PT 48 54 176.84 $12003.61 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 0.57 $31.04 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 0.93 $0.93 $1.00
SENS -V5264 EARMOLD 2 3 7.38 $138.11 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 11.86 $592.86 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 142 168 734.62 $49866.17 $67.88
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 196 296 103332.57 $51666.29 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 4 20.07 $1003.58 $50.00
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Subtotal (Total Children Is Unduplicated) 246 846 105264.33 $170294.33 $1.62
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Total 992 105413.02 $178092.76 $1.69
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Number of Children (Unduplicated) With at Least One Authorization 273