Summary Report for FSPSAs Ending During the Report Period Center: 04
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: 04/01/09 and 06/30/09 Date of Report: 08-25-09 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
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 1.00 $37.00 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 1.00 $37.00 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 7 7 7.00 $339.50 $48.50
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.00 $239.20 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 42 43 43.43 $2171.43 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 111 120 147.86 $7171.07 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 80 82 90.00 $4365.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 136 146 158.71 $7697.64 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 2.37 $118.34 $50.00
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Subtotal (Total Children Is Unduplicated) 288 401 452.37 $22148.98 $48.96
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 8 9 23.20 $1160.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 96 109 164.35 $8217.63 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 36 39 58.27 $2913.34 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 18 18 29.10 $1455.01 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 63 73 96.91 $4845.49 $50.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 41 52 266.43 $6660.71 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 385 433 2881.82 $144091.18 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 170 190 879.66 $59711.27 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.57 $85.36 $54.32
PHY -97110 PT SESSION BY LICENSED PT 163 176 743.33 $50457.48 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 25 27 15.92 $15.92 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 4.00 $2000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.00 $65.00 $65.00
SENS -V5264 EARMOLD 2 2 5.73 $107.33 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 9 10 25.35 $1267.39 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 202 223 935.45 $63498.63 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 3.14 $41.49 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 290 359 1641.36 $820.68 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 5 6 32.29 $1614.41 $50.00
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Subtotal (Total Children Is Unduplicated) 585 1731 7808.89 $349028.29 $44.70
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Total 2133 8262.26 $371214.27 $44.93
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Number of Children (Unduplicated) With at Least One Authorization 606