Summary Report for FSPSAs Ending During the Report Period Center: 07
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: 01/01/09 and 03/31/09 Date of Report: 05-18-09 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 1.00 $37.00 $37.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 1 1 1.00 $37.00 $37.00
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 3 3 3.00 $108.21 $36.07
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.00 $8.83 $8.83
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 4.43 $553.58 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 3 3 15.57 $1946.44 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.00 $50.00 $50.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 2 2.00 $150.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.00 $111.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 29 39 56.00 $4200.00 $75.00
MED -MED UNSPECIFIED MED OFFICE VISIT 1 1 1.00 $150.00 $150.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 19 20 16.69 $809.68 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 2.00 $97.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 21 23 13.63 $660.94 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 58 59 50.54 $2451.40 $48.50
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 118 157 169.87 $11345.58 $66.79
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 2.40 $3600.00 $1500.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 4 4 4.00 $200.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 2 2 1.69 $84.59 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 1.85 $46.25 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 5 5 4.50 $225.00 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 3 4.97 $124.17 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 7 7 8.86 $442.92 $50.00
CONPP -CONPP CONSULT, PT, PHONE 2 2 3.62 $90.42 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 6 6 7.98 $399.17 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 3 3 5.83 $145.84 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 25.29 $316.07 $12.50
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 151 159 858.37 $42918.52 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 3 3 12.03 $601.67 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 31 34 200.86 $13634.18 $67.88
OCCT -97530HM OT SESSION BY OT ASST 13 13 51.86 $2816.89 $54.32
PHY -97110 PT SESSION BY LICENSED PT 52 54 323.16 $21935.93 $67.88
PHY -97110HM PT SESSION BY PT ASST 15 17 80.54 $4374.85 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 15 15 13.72 $13.72 $1.00
SENS -FM FM RECEIVER HEARING AID 1 1 1.00 $1650.00 $1650.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 97 99 599.54 $40696.70 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 1.00 $54.32 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 23 23 125.07 $1650.94 $13.20
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 299 457 2338.13 $136022.13 $58.18
-----------------------------------------------------------------------------------------------------------------------------
Total 615 2509.00 $147404.71 $58.75
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 359