Summary Report for FSPSAs Ending During the Report Period Center: 04
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: 07/01/09 and 09/30/09 Date of Report: 11-16-09 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 17 19 19.71 $956.14 $48.50
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.11 $66.67 $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 57.86 $2892.86 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 3 3 3.00 $150.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 148 167 166.67 $8083.34 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 124 138 159.71 $7746.14 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 168 193 209.43 $10157.29 $48.50
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Subtotal (Total Children Is Unduplicated) 343 554 620.49 $30338.44 $48.89
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 14.30 $715.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 74 78 96.91 $4845.35 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 0.67 $16.67 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 28 31 36.64 $1832.21 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 26 26 30.27 $1513.33 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 49 50 59.34 $2966.95 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 3.03 $75.83 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 78 93 499.36 $12483.93 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 428 509 2846.07 $142303.46 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 214 271 1294.14 $87846.45 $67.88
PHY -97110 PT SESSION BY LICENSED PT 192 241 1045.04 $70937.26 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 5.86 $318.16 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 19 21 19.56 $19.56 $1.00
SENS -V5264 EARMOLD 1 1 1.98 $37.02 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 11 14 31.55 $1577.38 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 239 294 1198.90 $81381.29 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 1.07 $14.14 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 348 436 2109.93 $1054.96 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 11 13 62.62 $3131.20 $50.00
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Subtotal (Total Children Is Unduplicated) 643 2087 9357.23 $413070.12 $44.14
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Total 2641 9977.72 $443408.56 $44.44
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Number of Children (Unduplicated) With at Least One Authorization 663