Summary Report for FSPSAs Ending During the Report Period Center: 06
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: 07/01/08 and 09/30/08 Date of Report: 11-18-08 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 7 7 3.60 $133.17 $37.00
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Subtotal (Total Children Is Unduplicated) 7 7 3.60 $133.17 $37.00
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 5 5 7.59 $455.14 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 2.93 $137.28 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 3.59 $429.41 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 7 7 9.00 $450.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 1.00 $48.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.00 $48.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 2 2 2.00 $97.00 $48.50
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Subtotal (Total Children Is Unduplicated) 18 19 27.11 $1665.83 $61.45
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 1.27 $63.34 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 17 20 30.00 $1500.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 13 13 10.12 $506.24 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 1.98 $49.58 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 12 13 10.12 $505.83 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.48 $12.08 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 10 10 8.93 $446.66 $50.00
CONPP -CONPP CONSULT, PT, PHONE 2 2 1.87 $46.67 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 10 11 9.17 $458.75 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.37 $34.17 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 10 10 126.57 $3164.29 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 106 121 855.66 $42782.86 $50.00
INTR -INTR INTERPRETER 9 9 46.14 $2307.14 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 103 112 458.05 $31092.12 $67.88
OCCT -97530HM OT SESSION BY OT ASST 4 5 18.00 $977.77 $54.32
PHY -97110 PT SESSION BY LICENSED PT 120 130 640.09 $43449.21 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 1.45 $78.76 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 2 2 2.00 $2.00 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 186 214 1126.53 $76468.56 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 9.86 $535.44 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 2.71 $35.83 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 6 8 9.47 $946.67 $100.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 5 5 30.79 $1539.29 $50.00
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Subtotal (Total Children Is Unduplicated) 291 695 3402.62 $207003.24 $60.84
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Total 721 3433.33 $208802.24 $60.82
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Number of Children (Unduplicated) With at Least One Authorization 302