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: 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 -V5010 ASSESSMENT FOR HEARING AID 4 4 4.00 $187.20 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 4.00 $478.40 $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) 6 10 10.00 $764.10 $76.41
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 4.00 $6000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 11 11 17.27 $863.38 $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 4 4 4.00 $100.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 11 11 18.84 $942.03 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 0.08 $1.88 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 16 16 23.71 $1185.42 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 0.86 $21.46 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 12 12 16.77 $838.63 $50.00
CONPP -CONPP CONSULT, PT, PHONE 2 2 3.75 $93.75 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 16 16 15.88 $793.76 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.39 $9.79 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 34 37 586.14 $14653.58 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 91 99 566.45 $28322.38 $50.00
INTR -INTR INTERPRETER 14 19 54.50 $2725.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 33 33 165.53 $11235.97 $67.88
OCCT -97530HM OT SESSION BY OT ASST 4 4 31.84 $1729.45 $54.32
PHY -97110 PT SESSION BY LICENSED PT 72 77 375.30 $25475.25 $67.88
PHY -97110HM PT SESSION BY PT ASST 5 5 21.21 $1152.36 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 8 8 10.13 $10.13 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 4 4 4.00 $2000.00 $500.00
SENS -V5264 EARMOLD 4 4 1.12 $21.01 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 120 133 717.36 $48694.66 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 23 23 109.64 $1447.29 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 15.43 $771.43 $50.00
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Subtotal (Total Children Is Unduplicated) 291 545 2784.20 $150088.57 $53.91
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Total 555 2794.20 $150852.67 $53.99
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Number of Children (Unduplicated) With at Least One Authorization 292