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: 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 0.22 $13.33 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 2.00 $93.60 $46.80
EXIT -EXIT TRANSITION ASSESSMENT 5 7 7.00 $350.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 36 46 46.00 $2231.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 15 16 22.57 $1094.71 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 18 19 19.00 $950.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 80 103 103.00 $4995.50 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.00 $50.00 $50.00
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Subtotal (Total Children Is Unduplicated) 122 194 200.79 $9778.14 $48.70
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 5 7.00 $10500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 4 4 4.67 $233.34 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 62 73 107.56 $5378.22 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 39 41 57.48 $2874.17 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 23 25 40.37 $2018.34 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 64 71 103.30 $5164.89 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 93 124 573.05 $28652.56 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 7.43 $371.43 $50.00
INTR -INTR INTERPRETER 4 4 7.00 $350.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 57 62 402.71 $27335.76 $67.88
OCCT -97530HM OT SESSION BY OT ASST 3 3 6.54 $355.02 $54.32
PHY -97110 PT SESSION BY LICENSED PT 50 58 303.80 $20621.85 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 1.90 $103.21 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 5 5 1.87 $1.87 $1.00
SENS -V5264 EARMOLD 1 1 0.44 $8.32 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 7.43 $371.43 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 147 168 799.20 $54249.79 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 7 7 48.93 $645.86 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 200 338 119598.57 $59799.28 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 8 9 21.39 $1069.53 $50.00
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Subtotal (Total Children Is Unduplicated) 247 1002 122100.63 $220104.83 $1.80
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Total 1196 122301.43 $229882.98 $1.88
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Number of Children (Unduplicated) With at Least One Authorization 278