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: 04/01/10 and 06/30/10 Date of Report: 08-17-10 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
EXIT -EXIT TRANSITION ASSESSMENT 2 2 2.00 $100.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 33 38 38.00 $1843.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 16 21 27.86 $1351.07 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 25 25 25.00 $1250.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 64 84 84.00 $4074.00 $48.50
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Subtotal (Total Children Is Unduplicated) 126 171 177.86 $8737.67 $49.13
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.43 $3649.95 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 1.00 $50.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 1.00 $50.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 2 4.73 $118.34 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 63 75 94.52 $4725.84 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 34 37 58.43 $2921.66 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 26 27 37.25 $1862.49 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 68 77 95.22 $4760.95 $50.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 8.86 $221.43 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 90 120 480.11 $24005.62 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 17.29 $864.29 $50.00
INTR -INTR INTERPRETER 2 2 1.87 $93.34 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 44 47 251.50 $17071.51 $67.88
OCCT -97530HM OT SESSION BY OT ASST 3 3 8.21 $445.81 $54.32
PHY -97110 PT SESSION BY LICENSED PT 46 52 214.01 $14526.75 $67.88
PHY -97110HM PT SESSION BY PT ASST 3 3 7.97 $432.88 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 9 9 5.31 $5.31 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 151 192 791.81 $53748.05 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 24.86 $328.11 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 205 310 109789.29 $54894.64 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 7 7 14.38 $719.05 $50.00
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Subtotal (Total Children Is Unduplicated) 252 972 111910.03 $185495.99 $1.66
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Total 1143 112087.89 $194233.67 $1.73
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Number of Children (Unduplicated) With at Least One Authorization 285