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: 07/01/09 and 09/30/09 Date of Report: 11-16-09 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 0.87 $9.36 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.87 $18.89 $21.79
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 0.52 $31.33 $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 8 8 8.00 $444.00 $55.50
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Subtotal (Total Children Is Unduplicated) 11 13 11.26 $623.18 $55.37
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.00 $3000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 4.68 $233.81 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 19 19 20.14 $1007.15 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 17 17 16.33 $816.67 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 11 12 12.00 $600.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 19 20 20.07 $1003.34 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 186 240 1091.71 $54585.55 $50.00
INTR -INTR INTERPRETER 3 3 3.00 $150.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 164 203 899.76 $61075.99 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 0.86 $46.56 $54.32
PHY -97110 PT SESSION BY LICENSED PT 186 235 921.77 $62569.93 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 11 12 12.00 $12.00 $1.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.00 $65.00 $65.00
SENS -V5264 EARMOLD 4 4 3.43 $64.27 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 3 3.00 $150.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 293 372 1866.07 $126669.14 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 15.43 $203.66 $13.20
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Subtotal (Total Children Is Unduplicated) 512 1154 4893.26 $312253.05 $63.81
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Total 1167 4904.52 $312876.23 $63.79
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Number of Children (Unduplicated) With at Least One Authorization 513