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: 10-01-11 and 12-31-11 Date of Report: 02-15-12 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 14 14 15.000000 $727.5000 $48.5000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.0000 $45.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 6 6 6.000000 $300.0000 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 93 101 101.000000 $4898.5000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 99 106 120.428572 $5840.7900 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 68 71 73.857143 $3582.0700 $48.5000
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Subtotal (Total Children Is Unduplicated) 230 299 317.285715 $15393.8600 $48.5200
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 1.000000 $50.0000 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 3 3 0.944444 $47.2200 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 4 5 1.866667 $93.3400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 2 2 0.800000 $40.0000 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 35 35 211.571430 $5289.2900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 436 491 2888.993650 $144449.6500 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 150 161 819.728569 $55643.1800 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 180 197 894.857142 $60742.8900 $67.8800
SCONLY-SCONLY SERVICE COORDINATION ONLY 11 11 10.533333 $10.5300 $1.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 10 10 24.380953 $1219.0500 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 138 143 705.928568 $47918.4500 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 1.428571 $18.8600 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 423 560 2793.809525 $1396.9000 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 7 7 21.376191 $1068.8100 $50.0000
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Subtotal (Total Children Is Unduplicated) 599 1627 8377.219043 $317988.1600 $37.9600
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Total 1926 8694.504758 $333382.0200 $38.3400
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Number of Children (Unduplicated) With at Least One Authorization 608