Summary Report for FSPSAs Initiated During the Report Period Center: 53
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
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 7 7 7.00 $339.50 $48.50
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.31 $71.30 $54.38
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 62 63 67.91 $8121.99 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 13 13 13.00 $630.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 14 14 15.50 $751.75 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 1 1 1.00 $50.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 37 37 39.00 $1891.50 $48.50
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Subtotal (Total Children Is Unduplicated) 91 139 147.72 $12075.14 $81.74
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 8 11 12.00 $18000.00 $1500.00
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 4.07 $280.36 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 14.90 $745.24 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 14 14 19.00 $950.24 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 3 3 6.32 $157.92 $25.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.17 $54.17 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 7 8 15.36 $768.10 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 4 4 3.97 $198.34 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 5 5 9.98 $249.41 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 35 35 63.92 $1597.98 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 172 181 928.22 $46410.97 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 1 8.43 $421.43 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 6 6 32.40 $1619.77 $50.00
OCCT -97530HM OT SESSION BY OT ASST 14 15 102.65 $5575.82 $54.32
PHY -97110HM PT SESSION BY PT ASST 21 22 146.11 $7936.93 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 10 10 5.66 $5.66 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.16 $10.15 $65.00
SENS -V5264 EARMOLD 2 2 3.89 $72.80 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 4 4 12.03 $601.67 $50.00
SPL -92508 GROUP SPL SESSION PER CHILD 11 12 116.14 $1533.09 $13.20
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Subtotal (Total Children Is Unduplicated) 214 340 1508.37 $87690.02 $58.14
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Total 479 1656.09 $99765.16 $60.24
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Number of Children (Unduplicated) With at Least One Authorization 228