Summary Report for FSPSAs Initiated During the Report Period Center: 55
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 -V5090 DISPENSING FEE PER HEARING AID 1 1 2.00 $239.20 $119.60
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 6 6 6.00 $291.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 6 6 7.00 $339.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 4 4 4.00 $194.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 8 8 8.00 $388.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 24 26 26.00 $1261.00 $48.50
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Subtotal (Total Children Is Unduplicated) 42 51 53.00 $2712.70 $51.18
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 1.50 $75.00 $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 1.00 $50.00 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 0.53 $13.33 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 1 1 1.77 $88.34 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 3.00 $150.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 5 5 7.67 $383.34 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 3 3 12.90 $322.50 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 27 27 203.57 $10178.56 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 10.43 $521.43 $50.00
INTR -INTR INTERPRETER 1 1 7.29 $364.29 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 46 48 345.07 $23423.43 $67.88
PHY -97110 PT SESSION BY LICENSED PT 20 21 159.50 $10826.85 $67.88
PHY -97110HM PT SESSION BY PT ASST 5 5 19.64 $1067.00 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 1.00 $1.00 $1.00
SENS -V5264 EARMOLD 2 2 3.09 $57.82 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 101 104 685.68 $46543.84 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 12.93 $170.66 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 96 109 984.86 $492.43 $0.50
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Subtotal (Total Children Is Unduplicated) 145 341 2464.42 $96329.81 $39.09
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Total 392 2517.42 $99042.51 $39.34
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Number of Children (Unduplicated) With at Least One Authorization 152