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: 01/01/10 and 03/31/10 Date of Report: 05-17-10 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 5.20 $243.36 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 3.00 $358.80 $119.60
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Subtotal (Total Children Is Unduplicated) 4 7 8.20 $602.16 $73.43
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 12 13 16.26 $812.78 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 6 7 7.50 $375.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 2 2 0.75 $18.75 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1 1 0.27 $13.34 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 14 16 16.81 $840.42 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 7 7 10.62 $530.83 $50.00
CONPP -CONPP CONSULT, PT, PHONE 3 3 1.72 $42.92 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 8 8 14.77 $738.46 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 3 3 2.31 $57.71 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 36 43 454.86 $11371.43 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 120 132 770.65 $38532.65 $50.00
INTR -INTR INTERPRETER 29 32 62.57 $3128.57 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 32 45 136.19 $9244.77 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 12.14 $659.60 $54.32
PHY -97110 PT SESSION BY LICENSED PT 109 132 475.49 $32276.33 $67.88
PHY -97110HM PT SESSION BY PT ASST 2 2 12.71 $690.64 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 26 30 30.00 $30.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 3 3.00 $1500.00 $500.00
SENS -V5264 EARMOLD 3 3 0.93 $17.47 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 208 250 1020.97 $69303.43 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 9 10 54.50 $719.40 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 1.00 $100.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 2 2 36.00 $18.00 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 7.29 $364.29 $50.00
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Subtotal (Total Children Is Unduplicated) 394 750 3150.30 $172886.76 $54.88
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Total 757 3158.50 $173488.92 $54.93
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Number of Children (Unduplicated) With at Least One Authorization 395