Summary Report for FSPSAs Initiated During the Report Period Center: 04
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: 04/01/09 and 06/30/09 Date of Report: 08-25-09 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 10 10.00 $485.00 $48.50
EVAL -EVAL DEVELOPMENTAL EVALUATION 16 16 16.00 $800.00 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 1 1 1.00 $50.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 120 135 156.29 $7579.86 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 93 102 102.71 $4981.64 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 139 163 175.29 $8501.36 $48.50
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Subtotal (Total Children Is Unduplicated) 279 427 461.29 $22397.86 $48.56
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 4 5 5.00 $250.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 50 54 96.19 $4809.51 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 0.07 $1.67 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 16 17 27.58 $1378.89 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 9 9 18.07 $903.33 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 40 43 71.61 $3580.54 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.83 $45.83 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 40 56 185.71 $4642.87 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 395 445 2421.09 $121054.43 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 185 211 860.43 $58405.89 $67.88
PHY -97110 PT SESSION BY LICENSED PT 167 188 808.52 $54882.11 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 0.43 $23.28 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 22 23 21.11 $21.11 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 8 8 20.39 $1019.52 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 211 243 1035.64 $70299.47 $67.88
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 313 375 1917.76 $958.88 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 11 13 29.96 $1497.98 $50.00
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Subtotal (Total Children Is Unduplicated) 575 1693 7521.39 $323775.30 $43.05
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Total 2120 7982.67 $346173.16 $43.37
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Number of Children (Unduplicated) With at Least One Authorization 584