Summary Report for FSPSAs Initiated During the Report Period Center: 06
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: 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 4 4 4.00 $187.20 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 4.00 $478.40 $119.60
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.00 $48.50 $48.50
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Subtotal (Total Children Is Unduplicated) 5 9 9.00 $714.10 $79.34
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 13 13 25.85 $1292.70 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 10 14 9.50 $475.00 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 5 5 8.72 $217.98 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 4 6.75 $337.62 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 3 1.33 $33.33 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 6 8 11.42 $571.19 $50.00
CONPP -CONPP CONSULT, PT, PHONE 2 2 0.43 $10.83 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 4 4 7.08 $354.05 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 4 4 8.88 $221.94 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 21 22 431.21 $10780.36 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 120 129 805.00 $40250.25 $50.00
INTR -INTR INTERPRETER 32 34 73.00 $3650.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 48 50 210.85 $14312.50 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 3 15.07 $818.68 $54.32
PHY -97110 PT SESSION BY LICENSED PT 88 98 452.87 $30740.56 $67.88
PHY -97110HM PT SESSION BY PT ASST 5 7 14.50 $787.65 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 13 14 14.43 $14.43 $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 3.54 $66.35 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 172 186 963.74 $65418.90 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 38.07 $502.54 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 3 3 110.86 $55.43 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 22.00 $1100.00 $50.00
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Subtotal (Total Children Is Unduplicated) 354 617 3239.13 $174012.29 $53.72
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Total 626 3248.13 $174726.39 $53.79
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Number of Children (Unduplicated) With at Least One Authorization 354