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: 04/01/09 and 06/30/09 Date of Report: 08-25-09 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 0.70 $42.00 $60.00
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
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 3 3 3.00 $145.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.00 $48.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 2 2 2.00 $97.00 $48.50
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Subtotal (Total Children Is Unduplicated) 10 16 14.70 $998.60 $67.93
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.00 $3000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 6 6 8.06 $403.05 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 18 20 22.00 $1100.00 $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 7 9.00 $450.00 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 4 4 1.12 $27.92 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 19 21 30.45 $1522.74 $50.00
CONOP -CONOP CONSULT, OT, PHONE 4 4 4.27 $106.67 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 12 13 19.91 $995.59 $50.00
CONPP -CONPP CONSULT, PT, PHONE 3 3 1.40 $35.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 24 24 30.57 $1528.45 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 5 5 3.91 $97.71 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 33 38 494.43 $12360.71 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 103 112 567.75 $28387.26 $50.00
INTR -INTR INTERPRETER 15 15 30.29 $1514.29 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 43 47 184.54 $12526.72 $67.88
OCCT -97530HM OT SESSION BY OT ASST 5 5 16.41 $891.37 $54.32
PHY -97110 PT SESSION BY LICENSED PT 82 89 429.26 $29137.84 $67.88
PHY -97110HM PT SESSION BY PT ASST 6 8 27.61 $1499.63 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 5 5 4.37 $4.37 $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 2.83 $53.04 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 138 154 707.62 $48033.38 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 16 18 60.64 $800.49 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 1.00 $100.00 $100.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 8.29 $414.29 $50.00
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Subtotal (Total Children Is Unduplicated) 309 612 2672.71 $147015.49 $55.01
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Total 628 2687.41 $148014.09 $55.08
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Number of Children (Unduplicated) With at Least One Authorization 310