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: 10/01/09 and 12/31/09 Date of Report: 02-15-10 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 -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.00 $119.60 $119.60
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Subtotal (Total Children Is Unduplicated) 1 2 2.00 $166.40 $83.20
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.00 $3000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 10 10 16.17 $808.61 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 8 12 8.00 $400.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1 1 2.83 $141.67 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 2 3 0.90 $22.50 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 10 11 18.57 $928.46 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 3 1.33 $33.33 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 15 18 24.25 $1212.39 $50.00
CONPP -CONPP CONSULT, PT, PHONE 2 2 2.23 $55.83 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 7 9 10.80 $540.13 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 3 4 5.03 $125.84 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 38 42 488.36 $12208.93 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 138 150 854.05 $42702.38 $50.00
INTR -INTR INTERPRETER 32 34 66.00 $3300.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 48 52 229.71 $15592.53 $67.88
OCCT -97530HM OT SESSION BY OT ASST 4 4 7.50 $407.40 $54.32
PHY -97110 PT SESSION BY LICENSED PT 81 86 342.06 $23219.26 $67.88
PHY -97110HM PT SESSION BY PT ASST 6 7 30.93 $1680.04 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 22 23 23.37 $23.37 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $500.00
SENS -V5264 EARMOLD 1 1 0.37 $6.86 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 182 201 904.82 $61419.09 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 13 13 46.14 $609.09 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 12.57 $628.57 $50.00
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Subtotal (Total Children Is Unduplicated) 416 691 3099.00 $169566.28 $54.72
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Total 693 3101.00 $169732.68 $54.73
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Number of Children (Unduplicated) With at Least One Authorization 416