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: 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 -AUDE UNSPECIFIED AUDE SERVICES 11 11 11.00 $660.00 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 6 6 6.00 $717.60 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 2 2 2.00 $250.00 $125.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 55 55 55.00 $2667.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 52 52 52.00 $2522.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 165 166 191.43 $9284.29 $48.50
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Subtotal (Total Children Is Unduplicated) 225 292 317.43 $16101.39 $50.72
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.00 $4500.00 $1500.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 90 90 166.06 $8303.00 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 11 11 9.48 $237.09 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 7 7 2.12 $106.11 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.14 $3.47 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 7 7 2.02 $101.11 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.63 $15.83 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 186 188 228.19 $11409.64 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 13 13 7.21 $180.21 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 12.00 $881.04 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 12 13 76.57 $1914.29 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 0.43 $10.72 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 239 243 1611.73 $80586.52 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 55 57 230.43 $15641.50 $67.88
OCCT -97530HM OT SESSION BY OT ASST 10 10 32.86 $1784.81 $54.32
PHY -97110 PT SESSION BY LICENSED PT 48 48 173.47 $11775.33 $67.88
PHY -97110HM PT SESSION BY PT ASST 8 8 22.93 $1245.49 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 3 3 2.17 $2.17 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 3 11.46 $572.86 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 197 202 897.50 $60922.42 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 7 7 43.36 $572.31 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 236 259 1584.63 $792.31 $0.50
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Subtotal (Total Children Is Unduplicated) 347 1176 5118.39 $201558.22 $39.38
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Total 1468 5435.82 $217659.61 $40.04
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Number of Children (Unduplicated) With at Least One Authorization 359