Summary Report for FSPSAs Ending During the Report Period Center: 52
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: 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
Screening, Eval, and Assessment, Class # 02
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 2 3 5.00 $625.00 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 4 5 5.00 $250.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 33 36 36.00 $1746.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 12 15 15.00 $727.50 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 3 3 3.00 $150.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 47 52 52.23 $2533.32 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.00 $50.00 $50.00
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Subtotal (Total Children Is Unduplicated) 87 117 119.23 $6178.82 $51.82
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.00 $3000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 1.00 $50.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 26 30 34.00 $1699.99 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 16 16 15.17 $758.33 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 18 18 20.20 $1009.99 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 32 38 41.60 $2080.00 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 69 80 316.95 $15847.32 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 16.00 $800.00 $50.00
INTR -INTR INTERPRETER 1 3 6.00 $300.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 43 44 307.64 $20882.79 $67.88
PHY -97110 PT SESSION BY LICENSED PT 54 57 267.47 $18155.71 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 4 4 2.82 $2.82 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 2.29 $114.29 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 112 129 603.94 $40995.33 $67.88
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 151 243 91975.40 $45987.70 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 4 13.00 $650.00 $50.00
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Subtotal (Total Children Is Unduplicated) 201 672 93625.47 $152334.27 $1.63
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Total 789 93744.71 $158513.08 $1.69
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Number of Children (Unduplicated) With at Least One Authorization 222