Summary Report for FSPSAs Initiated During the Report Period Center: 09
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
Service Coordination, Class # 01
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1 0.14 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 1 1 0.14 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 2 0.88 $41.08 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 2 2.00 $239.20 $119.60
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Subtotal (Total Children Is Unduplicated) 1 4 2.88 $280.28 $97.39
EI Services, Class # 03
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 0.23 $16.04 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 3 4 12.85 $642.38 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 19 20 21.13 $1056.67 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 5 5 10.45 $522.39 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 5 5 3.93 $196.67 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 14 14 16.14 $806.91 $50.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 4.29 $214.29 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 236 306 1523.07 $76153.38 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 178 223 995.34 $67563.44 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.00 $54.32 $54.32
PHY -97110 PT SESSION BY LICENSED PT 191 254 1173.44 $79653.08 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 24 25 38.76 $38.76 $1.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.00 $65.00 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 2 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 3 4 2.82 $52.83 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 7 7 7.00 $350.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 339 445 2175.13 $147647.83 $67.88
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Subtotal (Total Children Is Unduplicated) 597 1318 5988.57 $375508.20 $62.70
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Total 1323 5991.59 $375788.48 $62.72
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Number of Children (Unduplicated) With at Least One Authorization 598