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: 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 -V5090 DISPENSING FEE PER HEARING AID 3 3 6.00 $717.60 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.00 $50.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 2 2 2.00 $100.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 3 3 3.00 $145.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 21 22 31.57 $1531.22 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 6 8 13.86 $672.07 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 9 9 9.00 $436.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 28 30 35.86 $1739.07 $48.50
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Subtotal (Total Children Is Unduplicated) 64 78 102.29 $5391.96 $52.71
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 2.00 $100.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 5 5 5.00 $250.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 3 3 3.00 $150.00 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 3 3 5.23 $130.84 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 7 7 21.71 $1085.48 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 2.47 $61.67 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 4 4 3.09 $154.45 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 6 6 12.25 $306.25 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 32 33 180.02 $9000.95 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 3 3 173.71 $8685.72 $50.00
INTR -INTR INTERPRETER 1 1 0.86 $42.86 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 57 57 348.29 $23642.22 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.07 $58.20 $54.32
PHY -97110 PT SESSION BY LICENSED PT 28 29 156.41 $10616.86 $67.88
PHY -97110HM PT SESSION BY PT ASST 4 4 24.29 $1319.20 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 5 5 5.00 $5.00 $1.00
SENS -FM FM RECEIVER HEARING AID 1 1 2.00 $3300.00 $1650.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 9.80 $2323.78 $237.12
SENS -V5264 EARMOLD 3 3 6.02 $112.73 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 142 146 826.54 $56105.22 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 9.86 $130.12 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 145 177 1352.02 $676.01 $0.50
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Subtotal (Total Children Is Unduplicated) 211 497 3150.63 $118257.53 $37.53
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Total 575 3252.92 $123649.49 $38.01
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Number of Children (Unduplicated) With at Least One Authorization 222