Summary Report for FSPSAs Ending During the Report Period Center: 57
This report shows the total number of units/fees for FSPSAs ending during the report period.
(i.e., end 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 ending 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 -AUDE UNSPECIFIED AUDE SERVICES 11 11 11.00 $660.00 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 3.00 $358.80 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 2 2 2.00 $250.00 $125.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 43 43 43.00 $2085.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 65 66 66.00 $3201.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 173 186 219.86 $10663.07 $48.50
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Subtotal (Total Children Is Unduplicated) 227 311 344.86 $17218.37 $49.93
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 2.00 $100.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 166 170 224.81 $11240.49 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 15 15 26.77 $669.19 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 8 9 24.98 $1249.05 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.00 $25.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 5 5 7.43 $371.67 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 5.43 $135.72 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 202 216 277.22 $13860.84 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 12 12 20.41 $510.35 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 12.00 $881.04 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 8 8 64.43 $1610.72 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 244 268 1666.91 $83345.46 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 49 51 239.71 $16271.81 $67.88
OCCT -97530HM OT SESSION BY OT ASST 5 5 22.86 $1241.60 $54.32
PHY -97110 PT SESSION BY LICENSED PT 62 64 307.29 $20858.55 $67.88
PHY -97110HM PT SESSION BY PT ASST 10 10 41.03 $2228.68 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 5 5 2.18 $2.18 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 4 4 17.91 $895.72 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 199 217 899.93 $61087.15 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 9 9 32.29 $426.17 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 0.71 $71.43 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 253 303 2360.33 $1180.17 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 10.00 $500.00 $50.00
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Subtotal (Total Children Is Unduplicated) 351 1379 6268.63 $220262.95 $35.14
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Total 1690 6613.49 $237481.31 $35.91
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Number of Children (Unduplicated) With at Least One Authorization 357