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: 10/01/08 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 1 1 0.08 $3.08 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 0.08 $3.08 $37.00
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 3 3 13.50 $810.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 3.03 $141.96 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 3.18 $380.72 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 2 2 2.00 $100.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 1.00 $48.50 $48.50
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Subtotal (Total Children Is Unduplicated) 12 15 23.72 $1606.18 $67.72
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 3.92 $195.84 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 11 12 15.00 $750.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 1.00 $25.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 5 5 9.53 $476.66 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 18 19 18.82 $941.07 $50.00
CONOP -CONOP CONSULT, OT, PHONE 4 5 4.19 $104.79 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 10 10 13.60 $680.00 $50.00
CONPP -CONPP CONSULT, PT, PHONE 6 7 6.19 $154.79 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 17 17 23.00 $1150.00 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 9 12 15.42 $385.42 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 29 31 380.43 $9510.73 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 113 122 641.00 $32049.78 $50.00
INTR -INTR INTERPRETER 10 11 47.57 $2378.57 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 62 67 254.83 $17297.53 $67.88
PHY -97110 PT SESSION BY LICENSED PT 102 110 531.61 $36085.96 $67.88
PHY -97110HM PT SESSION BY PT ASST 2 2 3.87 $210.10 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 4 4 4.00 $4.00 $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 1.76 $32.86 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 179 204 984.28 $66813.15 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 33.71 $445.03 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 2 2 2.10 $210.00 $100.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 6 6 79.86 $3992.86 $50.00
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Subtotal (Total Children Is Unduplicated) 317 661 3079.18 $176644.12 $57.37
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Total 677 3102.98 $178253.38 $57.45
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Number of Children (Unduplicated) With at Least One Authorization 319