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: 07/01/08 and 09/30/08 Date of Report: 11-18-08 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 15 17 18.00 $873.00 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
EVAL -EVAL DEVELOPMENTAL EVALUATION 71 74 72.86 $3642.78 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 1 1 1.00 $50.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 91 95 100.87 $4892.26 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 86 95 95.93 $4652.77 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 106 112 112.90 $5475.65 $48.50
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Subtotal (Total Children Is Unduplicated) 272 395 402.56 $19622.53 $48.74
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 9 9 9.00 $450.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 231 252 415.83 $20791.44 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 104 112 185.30 $9265.00 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 66 69 118.69 $5934.64 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 124 136 198.19 $9909.31 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.23 $30.83 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 88 114 490.64 $12266.02 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 5.14 $128.57 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 349 411 2691.68 $134584.09 $50.00
INTR -INTR INTERPRETER 1 1 0.50 $25.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 128 152 532.85 $36169.53 $67.88
PHY -97110 PT SESSION BY LICENSED PT 149 182 732.46 $49719.53 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 6 6 3.97 $3.97 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 8 12 19.38 $969.05 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 149 170 574.70 $39010.46 $67.88
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 291 355 1044.49 $522.24 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 10 13 48.68 $2433.82 $50.00
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Subtotal (Total Children Is Unduplicated) 539 1996 7072.72 $322213.49 $45.56
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Total 2391 7475.28 $341836.02 $45.73
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Number of Children (Unduplicated) With at Least One Authorization 567