Summary Report for FSPSAs Ending During the Report Period Center: 06
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: 04/01/10 and 06/30/10 Date of Report: 08-17-10 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 4.00 $187.20 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 4.00 $478.40 $119.60
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.00 $48.50 $48.50
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Subtotal (Total Children Is Unduplicated) 5 9 9.00 $714.10 $79.34
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 11 11 18.93 $946.35 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 9 9 8.25 $412.50 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 4 4 1.50 $37.50 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1 1 2.77 $138.34 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 3 3 0.69 $17.26 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 11 12 27.31 $1365.54 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.50 $12.50 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 7 8 13.15 $657.38 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.42 $10.42 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 4 4 5.56 $277.86 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 5 5 1.76 $43.93 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 28 41 466.07 $11651.79 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 132 144 826.05 $41302.60 $50.00
INTR -INTR INTERPRETER 32 38 110.29 $5514.29 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 48 53 207.96 $14116.59 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 2 6.64 $360.84 $54.32
PHY -97110 PT SESSION BY LICENSED PT 107 120 495.45 $33630.98 $67.88
PHY -97110HM PT SESSION BY PT ASST 2 2 10.93 $593.64 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 30 32 32.00 $32.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 4 4 4.00 $2000.00 $500.00
SENS -V5264 EARMOLD 4 4 2.28 $42.64 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 218 248 1161.98 $78875.37 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 17 19 106.79 $1409.57 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 2 2.00 $200.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 7 7 97.71 $48.86 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 8.14 $407.15 $50.00
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Subtotal (Total Children Is Unduplicated) 438 776 3619.12 $194105.86 $53.63
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Total 785 3628.12 $194819.96 $53.70
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Number of Children (Unduplicated) With at Least One Authorization 438