Summary Report for FSPSAs Initiated During the Report Period Center: 52
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
Screening, Eval, and Assessment, Class # 02
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 4 4 6.00 $750.00 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 5 6 6.00 $300.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 29 38 38.00 $1843.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 15 18 18.00 $873.00 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 9 9 9.00 $450.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 51 55 55.00 $2667.50 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.00 $50.00 $50.00
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Subtotal (Total Children Is Unduplicated) 92 131 133.00 $6933.50 $52.13
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 4 5.00 $7500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 1.00 $50.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 46 50 67.57 $3378.46 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 22 24 33.46 $1673.03 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 23 26 36.50 $1825.12 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 51 57 64.23 $3211.67 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 85 101 415.83 $20791.32 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 14.86 $742.86 $50.00
INTR -INTR INTERPRETER 1 3 6.00 $300.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 38 40 250.51 $17004.78 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 4.07 $221.16 $54.32
PHY -97110 PT SESSION BY LICENSED PT 59 65 331.24 $22484.53 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 5.43 $294.88 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 0.66 $0.66 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 1.00 $50.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 119 136 610.88 $41466.45 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 7.21 $95.23 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 187 286 106262.29 $53131.14 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 4 10.43 $521.43 $50.00
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Subtotal (Total Children Is Unduplicated) 228 805 108128.16 $174742.69 $1.62
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Total 936 108261.16 $181676.19 $1.68
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Number of Children (Unduplicated) With at Least One Authorization 244