Summary Report for FSPSAs Initiated During the Report Period Center: 06
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: 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 4 4 2.35 $87.05 $37.00
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Subtotal (Total Children Is Unduplicated) 4 4 2.35 $87.05 $37.00
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 5 5 20.04 $1202.57 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 2.13 $99.84 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 2.47 $295.02 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.00 $50.00 $50.00
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.00 $48.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 1 1 1.00 $48.50 $48.50
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Subtotal (Total Children Is Unduplicated) 12 15 28.64 $1869.43 $65.27
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 2.00 $3000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 2.30 $115.00 $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 9 10 17.04 $852.08 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 1.40 $35.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 33 35 40.24 $2012.14 $50.00
CONOP -CONOP CONSULT, OT, PHONE 6 6 8.07 $201.67 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 20 20 28.78 $1439.05 $50.00
CONPP -CONPP CONSULT, PT, PHONE 5 5 6.36 $158.96 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 29 31 45.40 $2269.77 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 4 5 9.59 $239.76 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 42 42 503.43 $12585.73 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 82 93 583.37 $29168.58 $50.00
INTR -INTR INTERPRETER 9 9 26.93 $1346.43 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 52 56 271.03 $18397.72 $67.88
OCCT -97530HM OT SESSION BY OT ASST 3 4 39.14 $2126.24 $54.32
PHY -97110 PT SESSION BY LICENSED PT 80 87 393.96 $26742.00 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 1.00 $1.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 2.00 $1000.00 $500.00
SENS -V5264 EARMOLD 2 2 1.07 $19.97 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 153 170 935.23 $63483.74 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 12.71 $167.83 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 5 5 8.13 $813.34 $100.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 36.14 $1807.15 $50.00
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Subtotal (Total Children Is Unduplicated) 289 615 3005.33 $169483.14 $56.39
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Total 634 3036.33 $171439.62 $56.46
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Number of Children (Unduplicated) With at Least One Authorization 293