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: 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 2 2 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.00 $239.20 $119.60
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 6.14 $614.29 $100.00
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Subtotal (Total Children Is Unduplicated) 3 5 10.14 $947.09 $93.37
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 13 14 27.72 $1385.87 $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
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 6.20 $310.24 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.83 $45.83 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 5 5 6.36 $318.21 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.27 $6.67 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 4 4 5.03 $251.67 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 2 0.53 $13.34 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 28 38 316.43 $7910.73 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 135 153 898.10 $44904.78 $50.00
INTR -INTR INTERPRETER 30 36 73.14 $3657.15 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 44 59 222.86 $15127.55 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 8.89 $483.06 $54.32
PHY -97110 PT SESSION BY LICENSED PT 107 133 494.63 $33575.41 $67.88
PHY -97110HM PT SESSION BY PT ASST 3 3 6.29 $341.44 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 34 35 35.00 $35.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 2.00 $1000.00 $500.00
SENS -V5264 EARMOLD 2 2 1.60 $29.95 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 182 226 1004.21 $68166.11 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 14 16 125.86 $1661.32 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 2 2.00 $200.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 22 23 210.00 $105.00 $0.50
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Subtotal (Total Children Is Unduplicated) 401 774 3459.71 $181479.30 $52.46
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Total 779 3469.85 $182426.39 $52.57
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Number of Children (Unduplicated) With at Least One Authorization 401