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: 01/01/08 and 12/31/08 Date of Report: 02-16-09 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 21 21 18.02 $666.74 $37.00
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Subtotal (Total Children Is Unduplicated) 21 21 18.02 $666.74 $37.00
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 9 15 87.12 $5227.43 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 5 9.33 $436.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 7 7 29.39 $3515.38 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 2 2 25.29 $3160.71 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 124 151 206.00 $10300.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 5 5 5.00 $242.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 3.00 $145.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 5 5 5.00 $242.50 $48.50
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Subtotal (Total Children Is Unduplicated) 147 193 370.14 $23270.82 $62.87
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 5 5.00 $7500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 8 9 12.01 $600.44 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 73 82 111.00 $5550.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 3 3 3.00 $75.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 27 35 60.33 $3016.73 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 2 3 4.12 $102.92 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 32 46 78.16 $3908.20 $50.00
CONOP -CONOP CONSULT, OT, PHONE 7 8 12.75 $318.75 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 31 38 64.96 $3248.19 $50.00
CONPP -CONPP CONSULT, PT, PHONE 9 11 18.50 $462.50 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 39 47 90.40 $4519.82 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 13 18 29.88 $747.06 $25.00
EIGF -T1024TTHN *EI GROUP SESSION BY PROF 21 21 540.14 $13503.57 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 59 82 2113.00 $52825.00 $25.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 53 54 553.53 $27676.42 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 32.86 $821.43 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 257 404 6834.10 $341705.06 $50.00
INTR -INTR INTERPRETER 41 55 342.93 $17146.43 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 220 375 3989.54 $270810.20 $67.88
OCCT -97530HM OT SESSION BY OT ASST 18 21 172.46 $9368.24 $54.32
PHY -97110 PT SESSION BY LICENSED PT 285 486 5696.21 $386658.49 $67.88
PHY -97110HM PT SESSION BY PT ASST 17 17 79.77 $4332.86 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 7 7 7.00 $7.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 3 2.50 $1250.00 $500.00
SENS -V5264 EARMOLD 3 3 1.82 $34.11 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 436 773 9325.42 $633009.28 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 8 8 38.64 $2099.07 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 15 15 146.00 $1927.26 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 16 30 41.07 $4106.68 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1 1 2.00 $1.00 $0.50
VISN -T1024HN *EI VISION SERVICES, INDIVIDUAL 9 9 46.64 $2332.15 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 11 15 386.00 $19300.00 $50.00
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Subtotal (Total Children Is Unduplicated) 668 2685 30841.75 $1818963.82 $58.98
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Total 2899 31229.90 $1842901.38 $59.01
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Number of Children (Unduplicated) With at Least One Authorization 675