Summary Report for FSPSAs Initiated During the Report Period Center: 09
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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 2 2 2.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 2 2 2.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 1.00 $48.50 $48.50
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 0.91 $54.67 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.00 $119.60 $119.60
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 1.00 $55.50 $55.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 1 2 2.00 $97.00 $48.50
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Subtotal (Total Children Is Unduplicated) 5 8 6.91 $422.07 $61.07
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 6 6 11.38 $569.12 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 8 8 8.23 $411.67 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 13 13 13.33 $666.67 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.00 $25.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 5 5 5.00 $250.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 18 18 22.77 $1138.34 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 6 6 6.14 $451.01 $73.42
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 1.00 $50.00 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 100 135 579.96 $28997.87 $50.00
INTR -INTR INTERPRETER 2 2 4.43 $221.43 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 150 188 839.06 $56955.07 $67.88
OCCT -97530HM OT SESSION BY OT ASST 3 3 2.53 $137.61 $54.32
PHY -97110 PT SESSION BY LICENSED PT 159 198 943.48 $64043.52 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 1.00 $1.00 $1.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 4 0.32 $13.55 $43.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 6 6 6.97 $130.41 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 261 359 1697.77 $115244.91 $67.88
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Subtotal (Total Children Is Unduplicated) 398 957 4147.37 $271281.41 $65.41
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Total 967 4156.28 $271703.48 $65.37
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Number of Children (Unduplicated) With at Least One Authorization 400