Summary Report for FSPSAs Initiated During the Report Period Center: 55
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: 01/01/10 and 03/31/10 Date of Report: 05-17-10 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 -V5090 DISPENSING FEE PER HEARING AID 1 1 1.00 $119.60 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 3 3 4.00 $200.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 3 3 3.00 $150.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 7 7 7.00 $339.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 26 26 35.57 $1725.22 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 7 8 13.86 $672.07 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 10 10 10.00 $485.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 35 36 41.08 $1992.62 $48.50
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Subtotal (Total Children Is Unduplicated) 71 94 115.51 $5684.00 $49.21
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 6.50 $325.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 5 5 5.00 $250.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 17 18 12.43 $621.38 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 15 15 23.67 $591.66 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 7 7 8.64 $432.22 $50.00
CONOP -CONOP CONSULT, OT, PHONE 7 8 13.43 $335.84 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 0.04 $2.22 $50.00
CONPP -CONPP CONSULT, PT, PHONE 2 2 2.80 $70.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 11 11 6.06 $302.78 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 14 14 18.02 $450.42 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 1.20 $30.00 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 38 38 232.66 $11633.08 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 3 3 10.03 $501.67 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 57 58 307.07 $20843.99 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.00 $54.32 $54.32
PHY -97110 PT SESSION BY LICENSED PT 39 40 234.64 $15927.53 $67.88
PHY -97110HM PT SESSION BY PT ASST 4 4 16.50 $896.28 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 2 2 2.00 $2.00 $1.00
SENS -V5264 EARMOLD 2 2 1.24 $23.30 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 4.29 $214.29 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 151 157 889.83 $60401.71 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 14.43 $783.76 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 29.14 $384.68 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 154 196 1401.46 $700.73 $0.50
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Subtotal (Total Children Is Unduplicated) 225 594 3242.09 $115778.84 $35.71
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Total 688 3357.60 $121462.85 $36.18
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Number of Children (Unduplicated) With at Least One Authorization 235