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: 04/01/10 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 43 44 50.00 $2425.00 $48.50
EVAL -EVAL DEVELOPMENTAL EVALUATION 10 10 10.00 $500.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 147 160 193.00 $9360.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 106 120 129.00 $6256.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 195 212 247.86 $12021.07 $48.50
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Subtotal (Total Children Is Unduplicated) 345 546 629.86 $30563.06 $48.52
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 2.00 $100.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 4 4 1.26 $63.06 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 2 2 0.84 $41.95 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 3 3 0.77 $38.61 $50.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 45 49 193.71 $4842.86 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 455 517 2706.05 $135302.36 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 1.00 $50.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 227 253 1244.79 $84496.16 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 8.36 $453.96 $54.32
PHY -97110 PT SESSION BY LICENSED PT 192 219 1131.43 $76801.41 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 16 16 15.38 $15.38 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 10 10 13.84 $691.99 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 279 309 1412.36 $95870.97 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 15.00 $198.00 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 9.14 $914.29 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 425 547 2673.48 $1336.74 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 9 10 31.58 $1578.81 $50.00
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Subtotal (Total Children Is Unduplicated) 630 1947 9460.99 $402796.54 $42.57
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Total 2493 10090.84 $433359.60 $42.95
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Number of Children (Unduplicated) With at Least One Authorization 641