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: 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 32 34 34.00 $1649.00 $48.50
EVAL -EVAL DEVELOPMENTAL EVALUATION 9 9 9.00 $450.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 145 156 179.29 $8695.36 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 96 107 107.00 $5189.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 148 160 181.14 $8785.43 $48.50
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Subtotal (Total Children Is Unduplicated) 307 466 510.43 $24769.28 $48.53
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 8 8 8.00 $400.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 12 12 17.63 $881.67 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 6 6 5.33 $266.67 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 0.18 $8.89 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 8 8 13.98 $699.05 $50.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 55 56 384.71 $9617.86 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 407 440 2853.33 $142666.50 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 221 240 1288.99 $87496.40 $67.88
PHY -97110 PT SESSION BY LICENSED PT 180 196 1022.18 $69385.51 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 22 24 19.41 $19.41 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 9 9 28.65 $1432.39 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 244 266 1317.71 $89445.99 $67.88
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 395 483 2591.30 $1295.65 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 10 10 24.18 $1208.82 $50.00
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Subtotal (Total Children Is Unduplicated) 591 1759 9575.57 $404824.78 $42.28
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Total 2225 10086.00 $429594.06 $42.59
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Number of Children (Unduplicated) With at Least One Authorization 599