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: 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 -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.17 $1.80 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.17 $3.63 $21.79
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 6.27 $376.38 $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 1 1 1.00 $55.50 $55.50
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Subtotal (Total Children Is Unduplicated) 4 6 8.61 $556.91 $64.71
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.00 $4500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 19.07 $953.58 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 18 19 29.41 $1470.72 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 20 21 22.85 $1142.38 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 10 11 12.48 $623.81 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 25 27 26.50 $1325.00 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 205 224 1081.06 $54053.11 $50.00
INTR -INTR INTERPRETER 3 3 3.00 $150.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 197 225 1026.24 $69661.38 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 12.00 $651.84 $54.32
PHY -97110 PT SESSION BY LICENSED PT 228 259 1075.85 $73028.75 $67.88
RSPT -RSPT RESPITE 1 1 1.00 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 16 16 17.77 $17.77 $1.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.16 $10.69 $65.00
SENS -V5264 EARMOLD 4 4 8.43 $157.78 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 3 3.00 $150.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 366 415 1914.84 $129979.62 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 10.57 $139.54 $13.20
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Subtotal (Total Children Is Unduplicated) 610 1240 5267.24 $338015.95 $64.17
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Total 1246 5275.85 $338572.86 $64.17
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Number of Children (Unduplicated) With at Least One Authorization 610