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: 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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 20 20 20.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 20 20 20.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 0.71 $42.67 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 3.00 $358.80 $119.60
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 4 4 4.00 $222.00 $55.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.00 $48.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 2 2 2.00 $97.00 $48.50
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Subtotal (Total Children Is Unduplicated) 11 13 11.71 $815.77 $69.66
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 8 8 14.26 $713.09 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 11 11 10.40 $520.00 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 13 15 16.87 $843.34 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.00 $25.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 8 8 8.00 $400.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 28 29 28.67 $1433.34 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 3 3 10.43 $765.67 $73.42
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 1.00 $50.00 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 143 161 847.95 $42397.40 $50.00
INTR -INTR INTERPRETER 3 4 20.43 $1021.43 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 171 209 933.45 $63362.54 $67.88
OCCT -97530HM OT SESSION BY OT ASST 3 4 20.00 $1086.40 $54.32
PHY -97110 PT SESSION BY LICENSED PT 200 238 1219.20 $82759.37 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 4 5 5.00 $5.00 $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 4 4 1.44 $93.49 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 8 8 5.38 $100.76 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 308 366 1828.11 $124091.92 $67.88
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Subtotal (Total Children Is Unduplicated) 487 1079 4975.58 $322142.99 $64.74
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Total 1112 5007.29 $322958.75 $64.50
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Number of Children (Unduplicated) With at Least One Authorization 490