Summary Report for FSPSAs Ending During the Report Period Center: 53
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
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 5 5 5.00 $242.50 $48.50
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 0.18 $9.67 $54.38
AUDE -V5010 ASSESSMENT FOR HEARING AID 5 5 5.00 $234.00 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 58 58 58.56 $7003.25 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 7 7 11.00 $1375.00 $125.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 1 1 2.53 $126.67 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 12 13 24.57 $1191.71 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 16 16 16.00 $776.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 24 27 44.86 $2175.57 $48.50
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Subtotal (Total Children Is Unduplicated) 96 133 167.70 $13134.37 $78.32
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 7 9.00 $13500.00 $1500.00
AUD -92633 AUD REHAB POSTLING HEARING LOSS 3 3 4.57 $314.79 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 7 7 15.76 $788.10 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 1.00 $25.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 18 18 26.38 $1319.05 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 4.50 $112.50 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 3.53 $176.67 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 3.73 $93.33 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 5 6 10.93 $546.43 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 8 8 31.81 $1590.72 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 4 4 6.07 $151.67 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 39 41 90.15 $2253.69 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 186 196 1084.72 $54236.20 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 2 2 5.28 $263.81 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 4 4 15.82 $790.95 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 3 4 76.29 $5178.28 $67.88
OCCT -97530HM OT SESSION BY OT ASST 15 15 226.29 $12291.84 $54.32
PHY -97110HM PT SESSION BY PT ASST 27 27 262.81 $14275.68 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 23 23 14.32 $14.32 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 3 3.00 $1500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 0.27 $17.45 $65.00
SENS -V5264 EARMOLD 4 4 3.91 $73.22 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 5 6 9.15 $457.39 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 10.00 $678.80 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 22 24 308.28 $4069.24 $13.20
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Subtotal (Total Children Is Unduplicated) 242 412 2227.56 $114719.10 $51.50
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Total 545 2395.25 $127853.48 $53.38
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Number of Children (Unduplicated) With at Least One Authorization 289