Summary Report for FSPSAs Ending During the Report Period Center: 09
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 -AUDE UNSPECIFIED AUDE SERVICES 4 4 9.17 $550.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 3.00 $358.80 $119.60
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 7 7 7.00 $388.50 $55.50
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Subtotal (Total Children Is Unduplicated) 13 15 20.17 $1344.10 $66.65
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.00 $3000.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 0.37 $25.25 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 6 6 10.39 $519.53 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 23 24 24.53 $1226.67 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 34 37 37.60 $1880.00 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 17 18 22.57 $1128.57 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 37 39 40.67 $2033.34 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 211 248 1152.55 $57627.64 $50.00
INTR -INTR INTERPRETER 2 2 2.00 $100.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 201 231 889.27 $60363.44 $67.88
OCCT -97530HM OT SESSION BY OT ASST 4 4 9.21 $500.52 $54.32
PHY -97110 PT SESSION BY LICENSED PT 211 235 991.47 $67301.26 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 12 12 12.00 $12.00 $1.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 4 3.17 $206.04 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 6 6 7.33 $137.28 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 7 7 6.30 $315.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 366 428 1899.12 $128912.49 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 5 6 16.29 $214.97 $13.20
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Subtotal (Total Children Is Unduplicated) 627 1312 5128.85 $325978.24 $63.56
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Total 1327 5149.02 $327322.34 $63.57
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Number of Children (Unduplicated) With at Least One Authorization 628