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: 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
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 44 46 47.00 $2279.50 $48.50
EVAL -EVAL DEVELOPMENTAL EVALUATION 11 11 11.00 $550.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 142 152 165.57 $8030.21 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 97 105 104.14 $5050.93 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 160 174 188.00 $9118.00 $48.50
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Subtotal (Total Children Is Unduplicated) 322 488 515.71 $25028.64 $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 7 8 2.98 $148.89 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 1.50 $75.00 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 0.44 $22.22 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 5 6 2.50 $125.00 $50.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 67 73 518.00 $12950.00 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 411 471 2751.47 $137573.27 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 221 244 1198.24 $81336.86 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 3.93 $213.40 $54.32
PHY -97110 PT SESSION BY LICENSED PT 185 202 946.64 $64258.04 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 21 24 20.98 $20.98 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 6 6 9.98 $499.16 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 260 291 1413.33 $95936.98 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 3.57 $47.14 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 382 506 2348.03 $1174.01 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 10 11 21.23 $1061.66 $50.00
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Subtotal (Total Children Is Unduplicated) 618 1856 9250.83 $395842.62 $42.79
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Total 2344 9766.54 $420871.26 $43.09
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Number of Children (Unduplicated) With at Least One Authorization 634