Summary Report for FSPSAs Initiated During the Report Period Center: 04
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: 10/01/08 and 12/31/08 Date of Report: 02-16-09 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
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 11 12 13.00 $630.50 $48.50
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.00 $239.20 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 37 37 38.00 $1900.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 99 107 119.14 $5778.43 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 69 76 120.29 $5833.86 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 120 127 135.86 $6589.07 $48.50
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Subtotal (Total Children Is Unduplicated) 244 361 429.29 $21017.86 $48.96
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 7.00 $350.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 100 103 192.44 $9621.91 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 34 34 66.74 $3336.89 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 24 24 48.73 $2436.66 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 63 66 110.53 $5526.68 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 1.00 $73.42 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 44 49 324.79 $8119.64 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 307 319 2208.65 $110432.39 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 157 171 787.32 $53443.15 $67.88
PHY -97110 PT SESSION BY LICENSED PT 137 151 756.42 $51345.80 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 23 24 16.61 $16.61 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 4.00 $2000.00 $500.00
SENS -V5264 EARMOLD 2 2 2.36 $44.10 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 11 12 32.14 $1606.91 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 179 195 869.49 $59020.97 $67.88
TRAN -TRAN FAMILY TRANSPORTATION 3 3 24.00 $2400.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 277 314 1524.15 $762.07 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 5 26.40 $1320.24 $50.00
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Subtotal (Total Children Is Unduplicated) 470 1480 7002.76 $311857.42 $44.53
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Total 1841 7432.05 $332875.27 $44.79
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Number of Children (Unduplicated) With at Least One Authorization 485