Summary Report for FSPSAs Ending During the Report Period Center: 54
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
Service Coordination, Class # 01
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 10.29 $380.57 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 10.29 $380.57 $37.00
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 40 40 39.15 $2349.19 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 16 17 17.00 $2033.20 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 1.00 $125.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 2 2 2.00 $250.00 $125.00
NURS -NURS NURSING ASSESSMENT 4 4 9.60 $480.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 6 6 6.00 $291.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 40 41 41.00 $1988.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 3 3 3.00 $145.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 16 16 16.00 $776.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 69 71 93.14 $4517.43 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 1.00 $100.00 $100.00
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Subtotal (Total Children Is Unduplicated) 155 203 229.90 $13102.62 $56.99
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 5 6 5.88 $293.89 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 3 3.97 $198.34 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 2.67 $66.67 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 83 85 144.15 $7207.48 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 5 5 8.25 $206.25 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 38 41 57.55 $2877.74 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.07 $1.67 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 25 25 26.38 $1319.17 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 71 74 108.03 $5401.66 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 3 3 4.05 $101.25 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 40.00 $500.00 $12.50
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 136 149 922.65 $46132.61 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 0.73 $36.67 $50.00
INTR -INTR INTERPRETER 12 12 91.54 $4576.79 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 74 76 507.88 $34474.95 $67.88
OCCT -97530HM OT SESSION BY OT ASST 7 7 42.50 $2308.61 $54.32
PHY -97110 PT SESSION BY LICENSED PT 57 66 320.23 $21737.25 $67.88
PHY -97110HM PT SESSION BY PT ASST 3 3 26.89 $1460.82 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 18 18 17.17 $17.17 $1.00
SENS -V5264 EARMOLD 2 2 1.88 $35.15 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 2.20 $109.77 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 107 113 651.61 $44231.40 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 32.21 $425.23 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 236 347 57395.56 $28697.78 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 32.71 $1635.72 $50.00
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Subtotal (Total Children Is Unduplicated) 311 1049 60446.76 $204054.00 $3.38
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Total 1253 60686.94 $217537.18 $3.58
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Number of Children (Unduplicated) With at Least One Authorization 336