Summary Report for FSPSAs Initiated During the Report Period Center: 09
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 -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.38 $3.34 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.38 $4.08 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.38 $8.23 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 0.38 $20.54 $54.38
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 0.53 $32.00 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.00 $119.60 $119.60
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 4 4 4.00 $222.00 $55.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 1 1 1.00 $48.50 $48.50
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Subtotal (Total Children Is Unduplicated) 8 11 8.04 $458.29 $56.97
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 4 4 14.44 $722.14 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 15 15 16.10 $805.00 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 24 24 25.43 $1271.67 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 15 15 15.00 $750.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 36 37 38.10 $1905.00 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 1 1 1.00 $50.00 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 145 172 808.60 $40430.04 $50.00
INTR -INTR INTERPRETER 3 3 3.00 $150.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 160 206 804.09 $54581.49 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 10.29 $558.72 $54.32
PHY -97110 PT SESSION BY LICENSED PT 174 215 866.51 $58818.54 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 11 13 13.00 $13.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $500.00
SENS -V5264 EARMOLD 4 4 16.20 $303.24 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 265 347 1567.04 $106370.76 $67.88
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Subtotal (Total Children Is Unduplicated) 454 1059 4199.80 $267229.59 $63.63
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Total 1070 4207.84 $267687.88 $63.62
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Number of Children (Unduplicated) With at Least One Authorization 456