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: 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
Service Coordination, Class # 01
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 0.84 $31.24 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 0.84 $31.24 $37.00
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 9 9 9.00 $540.00 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 10 10 10.00 $1196.00 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 49 49 52.30 $2536.55 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 69 70 70.00 $3395.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 156 160 161.47 $7831.14 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 11.00 $1100.00 $100.00
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Subtotal (Total Children Is Unduplicated) 213 300 314.77 $16723.69 $53.13
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 1.00 $50.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 20 20 29.66 $1482.78 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 20 20 7.77 $194.32 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 7 7 16.15 $807.30 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 1.02 $25.42 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 5 5 13.14 $657.11 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.39 $9.86 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 171 174 107.89 $5394.73 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 21 21 6.20 $154.94 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 7 7 39.86 $996.43 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 217 224 1525.50 $76275.09 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 49 49 202.50 $13745.73 $67.88
OCCT -97530HM OT SESSION BY OT ASST 10 10 40.07 $2176.69 $54.32
PHY -97110 PT SESSION BY LICENSED PT 70 71 356.89 $24225.92 $67.88
PHY -97110HM PT SESSION BY PT ASST 6 6 17.88 $971.03 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 5 5 3.59 $3.59 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 2.71 $135.64 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 177 181 839.89 $57012.03 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 15.14 $199.88 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 241 275 1841.65 $920.82 $0.50
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Subtotal (Total Children Is Unduplicated) 340 1087 5068.90 $185439.29 $36.58
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Total 1388 5384.52 $202194.22 $37.55
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Number of Children (Unduplicated) With at Least One Authorization 347