Summary Report for FSPSAs Ending During the Report Period Center: 06
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 3 3 6.74 $404.29 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 5.83 $273.00 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 3.00 $358.80 $119.60
EXIT -EXIT TRANSITION ASSESSMENT 1 1 1.00 $50.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 1.00 $48.50 $48.50
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Subtotal (Total Children Is Unduplicated) 9 12 17.57 $1134.58 $64.57
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 6 6.00 $9000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 7 7 8.27 $413.34 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 16 16 20.00 $1000.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 3 3 3.00 $75.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 15 16 18.66 $932.93 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 1.17 $29.17 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 27 27 30.32 $1515.83 $50.00
CONOP -CONOP CONSULT, OT, PHONE 5 5 5.50 $137.50 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 14 15 14.24 $712.09 $50.00
CONPP -CONPP CONSULT, PT, PHONE 4 4 4.58 $114.59 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 24 24 26.43 $1321.37 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 4 4 2.41 $60.21 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 25 26 371.71 $9292.86 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 90 98 525.25 $26262.63 $50.00
INTR -INTR INTERPRETER 13 17 37.93 $1896.43 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 45 47 197.93 $13435.23 $67.88
OCCT -97530HM OT SESSION BY OT ASST 3 3 9.43 $512.16 $54.32
PHY -97110 PT SESSION BY LICENSED PT 82 84 412.47 $27998.67 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 3.14 $170.72 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 9 9 9.00 $9.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 3 3.00 $1500.00 $500.00
SENS -V5264 EARMOLD 3 3 1.89 $35.36 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 141 154 728.08 $49422.08 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 41.86 $552.52 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 2 2 1.63 $163.33 $100.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 2.29 $114.29 $50.00
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Subtotal (Total Children Is Unduplicated) 299 583 2486.18 $146677.28 $59.00
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Total 595 2503.75 $147811.86 $59.04
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Number of Children (Unduplicated) With at Least One Authorization 300