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: 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 2 2 1.21 $72.86 $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 2 2 2.00 $111.00 $55.50
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Subtotal (Total Children Is Unduplicated) 5 5 4.21 $303.46 $72.01
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.00 $4500.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 0.66 $45.14 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 4 4 6.43 $321.43 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 11 11 11.00 $550.00 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 22 22 24.21 $1210.72 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 11 12 14.29 $714.29 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 14 18 18.00 $900.00 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 1.00 $73.42 $73.42
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 194 249 1169.31 $58465.30 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 180 217 1130.63 $76746.98 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 22.29 $1210.56 $54.32
PHY -97110 PT SESSION BY LICENSED PT 192 236 1116.93 $75817.44 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 14 15 17.00 $17.00 $1.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 2.08 $135.34 $65.00
SENS -V5264 EARMOLD 4 4 2.87 $53.72 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 6 6 7.90 $395.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 316 421 2131.43 $144681.48 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 4 5 19.00 $250.80 $13.20
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Subtotal (Total Children Is Unduplicated) 541 1230 5698.02 $366088.62 $64.25
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Total 1235 5702.23 $366392.08 $64.25
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Number of Children (Unduplicated) With at Least One Authorization 541