Summary Report for FSPSAs Ending During the Report Period Center: 54
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
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 39 39 37.26 $2235.33 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 7 7 7.00 $837.20 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 3 3 3.00 $375.00 $125.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 1.00 $75.00 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 4 5 5.23 $253.82 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 20 20 25.57 $1240.21 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 10 11 11.00 $533.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 14 14 21.29 $1032.36 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 59 60 69.00 $3346.50 $48.50
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Subtotal (Total Children Is Unduplicated) 117 161 181.35 $9975.71 $55.01
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 5.71 $285.72 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 2 2.53 $126.67 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.27 $6.67 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 50 53 75.45 $3772.27 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 1.20 $30.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 30 33 48.59 $2429.25 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 1.13 $28.34 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 11 11 20.18 $1009.18 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 42 42 73.84 $3692.03 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 2 2 2.00 $50.00 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 116 126 818.10 $40904.80 $50.00
INTR -INTR INTERPRETER 11 11 80.36 $4017.86 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 45 49 298.88 $20287.72 $67.88
OCCT -97530HM OT SESSION BY OT ASST 5 5 28.21 $1532.60 $54.32
PHY -97110 PT SESSION BY LICENSED PT 39 41 199.74 $13558.45 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 10.00 $543.20 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 10 10 10.00 $10.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.00 $65.00 $65.00
SENS -V5264 EARMOLD 2 2 1.13 $21.22 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 11.57 $578.57 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 67 70 466.79 $31685.41 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 1.71 $93.12 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 8 8 36.68 $484.16 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 175 248 36281.01 $18140.50 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 7.43 $371.43 $50.00
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Subtotal (Total Children Is Unduplicated) 224 727 38485.50 $144724.13 $3.76
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Total 888 38666.85 $154699.85 $4.00
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Number of Children (Unduplicated) With at Least One Authorization 250