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: 01/01/09 and 03/31/09 Date of Report: 05-18-09 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
Service Coordination, Class # 01
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 1.00 $37.00 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 1.00 $37.00 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 17 17 23.71 $1150.14 $48.50
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 0.64 $38.66 $60.00
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 30 31 31.00 $1550.00 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 2 2 2.00 $100.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 124 136 137.57 $6671.98 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 103 115 113.57 $5508.22 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 144 157 165.29 $8016.36 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 2.50 $125.00 $50.00
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Subtotal (Total Children Is Unduplicated) 304 462 479.28 $23446.36 $48.92
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 7 9 12.44 $621.90 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 87 97 153.16 $7658.07 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 41 45 58.17 $2908.32 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 28 32 41.80 $2090.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 56 59 80.71 $4035.47 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.50 $12.50 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 49 53 344.43 $8610.71 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 387 419 2296.18 $114808.94 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 191 211 884.57 $60044.72 $67.88
PHY -97110 PT SESSION BY LICENSED PT 179 203 824.36 $55957.65 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 20 21 15.78 $15.78 $1.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.00 $65.00 $65.00
SENS -V5264 EARMOLD 2 2 2.02 $37.86 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 6 7 11.67 $583.57 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 206 228 833.42 $56572.79 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 7.14 $94.29 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 2 2 5.21 $521.43 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 341 424 1668.52 $834.26 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 16.14 $807.15 $50.00
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Subtotal (Total Children Is Unduplicated) 575 1819 7257.23 $316280.37 $43.58
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Total 2282 7737.51 $339763.74 $43.91
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Number of Children (Unduplicated) With at Least One Authorization 590