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: 04/01/09 and 06/30/09 Date of Report: 08-25-09 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 1 1 1.00 $48.50 $48.50
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.00 $60.00 $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 1.69 $201.99 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 2 2 2.00 $100.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 47 56 56.00 $2716.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 14 16 16.00 $776.00 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 18 18 18.00 $900.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 47 58 57.97 $2811.39 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 1.00 $100.00 $100.00
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.00 $50.00 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 108 157 157.66 $7935.68 $50.34
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 3.00 $4500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 15.30 $765.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 50 55 86.77 $4338.34 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 29 30 33.82 $1690.83 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 23 23 31.53 $1576.67 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 45 51 85.47 $4273.69 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 103 117 519.96 $25997.87 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 13.14 $657.15 $50.00
INTR -INTR INTERPRETER 1 1 3.00 $150.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 59 61 303.68 $20614.06 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.43 $77.60 $54.32
PHY -97110 PT SESSION BY LICENSED PT 51 58 250.23 $16985.55 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 5 5 1.31 $1.31 $1.00
SENS -V5264 EARMOLD 2 2 5.38 $100.67 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 13.86 $692.86 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 133 161 660.83 $44857.07 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 2.71 $147.44 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 8.36 $110.31 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 210 319 111247.00 $55623.50 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 4 7.07 $353.58 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 252 899 113293.85 $183513.49 $1.62
-----------------------------------------------------------------------------------------------------------------------------
Total 1056 113451.51 $191449.16 $1.69
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 272