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: 10/01/09 and 12/31/09 Date of Report: 02-15-10 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
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.00 $60.00 $60.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 5 8 8.00 $400.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 46 57 57.00 $2764.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 21 23 23.00 $1115.50 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 19 19 19.00 $950.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 82 105 105.00 $5092.50 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 1.00 $100.00 $100.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 141 215 215.00 $10607.50 $49.34
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 6 9.00 $13500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 3.00 $150.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 60 64 82.92 $4145.84 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 31 32 40.72 $2035.83 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 23 23 31.48 $1574.16 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 53 55 84.90 $4245.01 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 105 129 569.23 $28461.42 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 2.71 $135.72 $50.00
INTR -INTR INTERPRETER 3 3 6.00 $300.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 54 59 329.32 $22354.36 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 12.54 $680.94 $54.32
PHY -97110 PT SESSION BY LICENSED PT 57 60 281.80 $19128.67 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 4 4 2.50 $2.50 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 4.57 $228.57 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 137 159 768.84 $52188.74 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 14.71 $194.23 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 198 341 120591.14 $60295.57 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 8 8 24.65 $1232.38 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 244 955 122860.03 $210853.91 $1.72
-----------------------------------------------------------------------------------------------------------------------------
Total 1170 123075.03 $221461.41 $1.80
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 284