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: 10/01/09 and 12/31/09 Date of Report: 02-15-10 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
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 16 17 20.71 $1004.64 $48.50
EVAL -EVAL DEVELOPMENTAL EVALUATION 18 18 18.00 $900.00 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 1 1 1.00 $50.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 139 157 164.29 $7967.86 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 116 121 121.00 $5868.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 174 191 206.43 $10011.79 $48.50
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Subtotal (Total Children Is Unduplicated) 326 505 531.43 $25802.79 $48.55
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 3.00 $150.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 33 37 33.15 $1657.55 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 3.37 $84.17 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 10 12 6.61 $330.56 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 7 7 2.64 $132.23 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 24 26 25.27 $1263.74 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.79 $19.72 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 56 59 371.71 $9292.85 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 392 432 2489.21 $124460.47 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 211 242 1080.64 $73353.97 $67.88
PHY -97110 PT SESSION BY LICENSED PT 195 210 963.14 $65378.08 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 17 20 16.51 $16.51 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 8 8 14.18 $709.05 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 250 285 1211.28 $82221.40 $67.88
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 352 428 2075.20 $1037.60 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 10 12 45.79 $2289.29 $50.00
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Subtotal (Total Children Is Unduplicated) 586 1784 8342.50 $362397.17 $43.44
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Total 2289 8873.93 $388199.96 $43.75
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Number of Children (Unduplicated) With at Least One Authorization 602