Summary Report for FSPSAs Initiated During the Report Period Center: 07
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 1 1 1.00 $37.00 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 1.00 $37.00 $37.00
Screening, Eval, and Assessment, Class # 02
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.00 $8.83 $8.83
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 2.00 $120.00 $60.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 4 4 19.36 $2420.24 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 3 3 3.00 $150.00 $50.00
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 29 38 62.50 $4687.50 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 2 2 2.00 $97.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 22 22 18.19 $882.24 $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 23 24 17.34 $841.20 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 57 60 49.37 $2394.32 $48.50
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Subtotal (Total Children Is Unduplicated) 105 157 175.76 $11649.83 $66.28
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.00 $3000.00 $1500.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 3 2.52 $125.84 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.75 $18.75 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 4 4 2.71 $135.42 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 1.60 $40.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 6 6 8.03 $401.67 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 2.33 $58.33 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 6 7 10.26 $512.92 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.30 $7.50 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 9 10 14.67 $733.34 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 3 3 2.03 $50.83 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 2 2 21.43 $267.86 $12.50
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 168 170 954.31 $47715.48 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 3.97 $198.34 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 30 31 183.50 $12455.98 $67.88
OCCT -97530HM OT SESSION BY OT ASST 13 13 83.21 $4520.20 $54.32
PHY -97110 PT SESSION BY LICENSED PT 36 37 264.36 $17944.88 $67.88
PHY -97110HM PT SESSION BY PT ASST 15 16 104.54 $5678.63 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 2 2 2.00 $2.00 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 87 90 607.07 $41208.03 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 8.86 $481.12 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 24 25 182.25 $2405.70 $13.20
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Subtotal (Total Children Is Unduplicated) 299 431 2462.70 $137962.79 $56.02
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Total 589 2639.46 $149649.62 $56.70
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Number of Children (Unduplicated) With at Least One Authorization 315