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: 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 16 16 17.41 $644.02 $37.00
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Subtotal (Total Children Is Unduplicated) 16 16 17.41 $644.02 $37.00
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 11 16 109.14 $6548.24 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 5 8 14.37 $672.36 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 7 8 25.11 $3002.81 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 120 145 194.00 $9700.00 $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 4 4 4.00 $194.00 $48.50
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Subtotal (Total Children Is Unduplicated) 143 190 355.61 $20630.41 $58.01
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 7 7.00 $10500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 11 12 17.16 $858.06 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 71 78 106.00 $5300.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 3 3 3.00 $75.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 28 34 100.03 $5001.68 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 4 6 7.13 $178.33 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 54 69 171.49 $8574.69 $50.00
CONOP -CONOP CONSULT, OT, PHONE 12 15 28.56 $713.96 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 37 40 120.75 $6037.54 $50.00
CONPP -CONPP CONSULT, PT, PHONE 11 16 24.97 $624.17 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 57 66 174.68 $8734.16 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 14 23 33.70 $842.48 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 74 100 2586.29 $64657.15 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 282 447 7023.77 $351188.52 $50.00
INTR -INTR INTERPRETER 43 55 332.71 $16635.72 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 193 307 3434.32 $233121.56 $67.88
OCCT -97530HM OT SESSION BY OT ASST 6 9 199.00 $10809.69 $54.32
PHY -97110 PT SESSION BY LICENSED PT 259 440 5249.98 $356368.78 $67.88
PHY -97110HM PT SESSION BY PT ASST 5 5 41.84 $2272.58 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 13 14 14.00 $14.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 4 5 4.50 $2250.00 $500.00
SENS -V5264 EARMOLD 4 5 3.44 $64.48 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 448 751 8915.25 $605166.89 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 19.93 $1082.52 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 9 9 124.14 $1638.69 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 16 28 38.37 $3836.67 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1 1 2.00 $1.00 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 13 16 382.21 $19110.71 $50.00
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Subtotal (Total Children Is Unduplicated) 699 2563 29166.23 $1715659.01 $58.82
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Total 2769 29539.25 $1736933.44 $58.80
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Number of Children (Unduplicated) With at Least One Authorization 708