Summary Report for FSPSAs Ending During the Report Period Center: 52
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
EXIT -EXIT TRANSITION ASSESSMENT 4 4 3.57 $178.57 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 36 42 42.00 $2037.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 17 21 21.00 $1018.50 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 24 24 24.00 $1200.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 60 77 77.00 $3734.50 $48.50
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Subtotal (Total Children Is Unduplicated) 132 168 167.57 $8168.57 $48.75
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 1.00 $50.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 1.00 $50.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 62 68 94.88 $4744.14 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 40 42 64.63 $3231.65 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 23 23 35.92 $1796.12 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 69 77 104.15 $5207.60 $50.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 7.86 $196.43 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 108 126 572.29 $28614.46 $50.00
INTR -INTR INTERPRETER 2 3 4.34 $217.23 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 50 56 378.07 $25663.50 $67.88
OCCT -97530HM OT SESSION BY OT ASST 5 5 23.38 $1270.06 $54.32
PHY -97110 PT SESSION BY LICENSED PT 57 61 303.25 $20584.83 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 1.10 $59.75 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 8 9 4.39 $4.39 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 2.00 $100.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 172 202 934.31 $63421.05 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 2.86 $37.71 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 207 331 129698.48 $64849.24 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 5 5 5.56 $278.09 $50.00
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Subtotal (Total Children Is Unduplicated) 263 1015 132239.48 $220376.23 $1.67
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Total 1183 132407.05 $228544.80 $1.73
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Number of Children (Unduplicated) With at Least One Authorization 308