Summary Report for FSPSAs Ending During the Report Period Center: 55
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 2.00 $239.20 $119.60
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 10 11 10.51 $509.79 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 21 21 22.00 $1067.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 6 7 7.00 $339.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 9 9 30.29 $1468.86 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 28 30 29.39 $1425.21 $48.50
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Subtotal (Total Children Is Unduplicated) 57 80 102.18 $5096.35 $49.87
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.00 $4500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 14.17 $708.34 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 2 2.00 $100.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1 1 0.40 $20.00 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 2.07 $103.34 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 2 2 4.60 $230.00 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 7.14 $357.15 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 31 33 189.27 $9463.34 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 12.14 $607.15 $50.00
INTR -INTR INTERPRETER 1 1 5.86 $292.86 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 65 73 451.07 $30618.73 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 0.07 $3.88 $54.32
PHY -97110 PT SESSION BY LICENSED PT 32 34 196.93 $13367.53 $67.88
PHY -97110HM PT SESSION BY PT ASST 4 4 11.36 $616.92 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 5 5 5.00 $5.00 $1.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 1 1 3.78 $70.72 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 141 150 882.75 $59921.08 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 9 9 43.64 $576.08 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 143 176 1365.27 $682.63 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 7.86 $392.86 $50.00
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Subtotal (Total Children Is Unduplicated) 203 503 3210.37 $123111.84 $38.35
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Total 583 3312.55 $128208.20 $38.70
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Number of Children (Unduplicated) With at Least One Authorization 217