Summary Report for FSPSAs Initiated During the Report Period Center: 55
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 -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.00 $10.80 $10.80
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.00 $54.38 $54.38
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.00 $28.28 $28.28
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 2 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.00 $239.20 $119.60
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 8 8 7.16 $347.05 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 7 7 15.71 $762.14 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 9 9 9.00 $436.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 6 6 6.00 $291.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 36 36 42.17 $2045.35 $48.50
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 53 72 87.04 $4308.30 $49.50
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 4.67 $233.34 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 4 4 4.00 $200.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 3 3 1.78 $89.17 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 2.10 $105.01 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 0.90 $45.00 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 26 26 160.29 $8014.29 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 2 2 4.17 $208.41 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 0.71 $35.72 $50.00
INTR -INTR INTERPRETER 1 1 0.71 $35.72 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 45 46 269.09 $18265.98 $67.88
OCCT -97530HM OT SESSION BY OT ASST 6 6 44.07 $2393.95 $54.32
PHY -97110 PT SESSION BY LICENSED PT 29 29 162.98 $11062.82 $67.88
PHY -97110HM PT SESSION BY PT ASST 6 6 52.00 $2824.63 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 2 2 3.03 $3.03 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -V5264 EARMOLD 1 1 1.24 $23.30 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 16.71 $835.72 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 87 89 494.14 $33542.41 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 8.29 $450.08 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 10 10 72.79 $960.77 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 82 101 645.54 $322.77 $0.50
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 154 336 1951.22 $80652.10 $41.33
-----------------------------------------------------------------------------------------------------------------------------
Total 408 2038.26 $84960.41 $41.68
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 164