Summary Report for FSPSAs Ending During the Report Period Center: 07
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: 10-01-11 and 12-31-11 Date of Report: 02-15-12 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 1 1 1.000000 $45.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.000000 $230.0000 $115.0000
EXIT -EXIT TRANSITION ASSESSMENT 1 1 2.000000 $100.0000 $50.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 4.000000 $300.0000 $75.0000
MED -MED UNSPECIFIED MED OFFICE VISIT 1 1 1.000000 $150.0000 $150.0000
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 1 1 1.000000 $50.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 6 8 13.000000 $986.0000 $75.8500
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 3.000000 $150.0000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 5 4.666667 $233.3400 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 63 69 76.733333 $3836.6700 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 7 8 8.000000 $200.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 17 17 17.600000 $880.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 2.000000 $50.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 15 16 16.000000 $800.0000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 32 33 31.900000 $1595.0000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 10 10 10.600000 $265.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 6 6 41.571429 $2078.5700 $50.0000
INTR -INTR INTERPRETER 2 2 4.000000 $200.0000 $50.0000
SCONLY-SCONLY SERVICE COORDINATION ONLY 48 50 48.311112 $48.3100 $1.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.000000 $456.0000 $228.0000
SENS -V5264 EARMOLD 1 1 2.000000 $36.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 2 9.000000 $610.9200 $67.8800
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 11 13 67.999999 $34.0000 $0.5000
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Subtotal (Total Children Is Unduplicated) 147 238 346.382540 $11498.8000 $33.2000
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Total 246 359.382540 $12484.8000 $34.7400
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Number of Children (Unduplicated) With at Least One Authorization 149