Summary Report for FSPSAs Initiated During the Report Period Center: 06
This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start 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 starting 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
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 2.49 $149.67 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 6.03 $282.36 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 3.00 $358.80 $119.60
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Subtotal (Total Children Is Unduplicated) 6 9 11.53 $790.83 $68.60
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.00 $3000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 7.97 $398.34 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 12 13 16.00 $800.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 1.00 $25.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 6 8 13.93 $696.67 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 1.17 $29.17 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 15 16 18.49 $924.40 $50.00
CONOP -CONOP CONSULT, OT, PHONE 4 5 3.76 $93.96 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 6 6 7.88 $394.05 $50.00
CONPP -CONPP CONSULT, PT, PHONE 6 7 6.20 $155.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 17 17 15.87 $793.68 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 8 13 9.93 $248.28 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 17 19 231.29 $5782.15 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 98 108 668.26 $33413.01 $50.00
INTR -INTR INTERPRETER 7 7 16.29 $814.29 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 42 45 200.71 $13624.09 $67.88
PHY -97110 PT SESSION BY LICENSED PT 73 79 376.04 $25525.79 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 10 10 10.00 $10.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 3 2.50 $1250.00 $500.00
SENS -V5264 EARMOLD 3 3 2.12 $39.73 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 136 161 814.27 $55272.96 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 3.14 $41.49 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 2 1.53 $153.33 $100.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 14.93 $746.43 $50.00
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Subtotal (Total Children Is Unduplicated) 265 535 2445.28 $144231.79 $58.98
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Total 544 2456.81 $145022.62 $59.03
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Number of Children (Unduplicated) With at Least One Authorization 265