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: 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 19 22 34.43 $1669.79 $48.50
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 0.93 $56.00 $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 2.00 $239.20 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 12 13 13.00 $650.00 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 1 1 1.14 $57.15 $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 155 184 200.71 $9734.64 $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 150 179 183.86 $8917.07 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 198 243 278.14 $13489.93 $48.50
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Subtotal (Total Children Is Unduplicated) 364 647 717.22 $34957.56 $48.74
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 9.50 $475.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 26 28 43.37 $2168.34 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 1.80 $45.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 9 10 5.77 $288.34 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 7 7 3.89 $194.44 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 12 13 10.03 $501.27 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.16 $3.89 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 81 116 478.93 $11973.24 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 454 553 2894.05 $144702.26 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 242 311 1295.00 $87904.79 $67.88
PHY -97110 PT SESSION BY LICENSED PT 236 295 1189.22 $80724.07 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 17 18 15.44 $15.44 $1.00
SENS -V5264 EARMOLD 1 1 1.00 $18.72 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 12 18 14.57 $728.34 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 298 375 1478.04 $100329.44 $67.88
TRAN -TRAN FAMILY TRANSPORTATION 1 1 9.43 $942.86 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 366 465 2054.02 $1027.01 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 11 15 51.94 $2596.91 $50.00
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Subtotal (Total Children Is Unduplicated) 665 2232 9557.14 $436139.34 $45.63
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Total 2879 10274.36 $471096.91 $45.85
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Number of Children (Unduplicated) With at Least One Authorization 674