Summary Report for FSPSAs Ending During the Report Period Center: 09
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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 120 120 120.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 120 120 120.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.34 $12.42 $36.07
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
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 4 4 4.00 $194.00 $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 2 2 2.00 $97.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 1 1 1.00 $48.50 $48.50
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Subtotal (Total Children Is Unduplicated) 12 12 11.34 $622.32 $54.86
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 0.47 $32.14 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 15.00 $750.01 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 7 7 8.77 $438.34 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 14 16 18.23 $911.67 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 10 11 11.00 $550.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 23 24 26.23 $1311.67 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 3 3 3.00 $220.26 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 1.00 $25.00 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 1.00 $50.00 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 1 1 1.00 $50.00 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 149 165 767.55 $38377.40 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 192 219 906.80 $61553.25 $67.88
OCCT -97530HM OT SESSION BY OT ASST 4 5 9.53 $517.85 $54.32
PHY -97110 PT SESSION BY LICENSED PT 174 206 813.26 $55203.95 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 1.00 $1.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 0.45 $29.38 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 5 5 3.18 $59.49 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 307 359 1663.87 $112943.43 $67.88
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Subtotal (Total Children Is Unduplicated) 493 1036 4255.33 $275499.06 $64.74
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Total 1168 4386.68 $276121.38 $62.95
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Number of Children (Unduplicated) With at Least One Authorization 513