Summary Report for FSPSAs Ending During the Report Period Center: 04
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: 01/01/09 and 03/31/09 Date of Report: 05-18-09 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
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 10 11 12.00 $582.00 $48.50
EVAL -EVAL DEVELOPMENTAL EVALUATION 51 54 54.00 $2700.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 116 123 132.26 $6414.47 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 103 107 120.65 $5851.41 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 138 150 160.94 $7805.50 $48.50
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Subtotal (Total Children Is Unduplicated) 290 445 479.84 $23353.38 $48.67
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 6 6 6.57 $328.57 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 123 137 210.60 $10530.04 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 60 67 107.41 $5370.74 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 48 56 77.93 $3896.46 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 72 76 122.50 $6125.01 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.50 $12.50 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 4 4 1.33 $97.48 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 61 67 399.30 $9982.51 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 347 387 2245.70 $112284.87 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 168 187 855.16 $58048.20 $67.88
PHY -97110 PT SESSION BY LICENSED PT 169 185 815.82 $55377.95 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 15 17 10.92 $10.92 $1.00
SENS -V5264 EARMOLD 1 1 2.00 $37.44 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 9 10 29.11 $1455.47 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 183 204 783.40 $53177.32 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 2.79 $36.77 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 11.57 $1157.14 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 286 338 1504.41 $752.21 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 5 5 29.75 $1487.50 $50.00
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Subtotal (Total Children Is Unduplicated) 546 1750 7216.77 $320169.07 $44.36
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Total 2195 7696.62 $343522.45 $44.63
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Number of Children (Unduplicated) With at Least One Authorization 559