Summary Report for FSPSAs Initiated During the Report Period Center: 57
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 13 13 13.00 $780.00 $60.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 30 30 30.00 $1455.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 40 40 40.00 $1940.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 114 114 133.00 $6450.50 $48.50
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Subtotal (Total Children Is Unduplicated) 148 198 217.00 $10750.50 $49.54
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 1.00 $50.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 152 154 315.95 $15797.63 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 8 8 7.69 $192.35 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 4 4 3.40 $170.00 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 5 5 6.58 $328.81 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.14 $28.57 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 150 152 310.11 $15505.69 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 8 8 7.69 $192.35 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 3 3 36.00 $2643.12 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 4 4 18.14 $453.57 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 13.14 $328.57 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 176 178 1316.29 $65814.28 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 30 30 131.64 $8935.93 $67.88
OCCT -97530HM OT SESSION BY OT ASST 6 6 16.86 $915.68 $54.32
PHY -97110 PT SESSION BY LICENSED PT 37 37 160.29 $10880.20 $67.88
PHY -97110HM PT SESSION BY PT ASST 7 7 18.00 $977.76 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 5 5 3.24 $3.24 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 6.44 $321.91 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 120 122 550.43 $37363.10 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 12 12 56.43 $744.86 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 12.57 $1257.14 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 183 203 3521.22 $1760.61 $0.50
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Subtotal (Total Children Is Unduplicated) 251 944 6514.26 $164665.36 $25.28
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Total 1142 6731.26 $175415.86 $26.06
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Number of Children (Unduplicated) With at Least One Authorization 257