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: 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 8 11 11.00 $533.50 $48.50
EVAL -EVAL DEVELOPMENTAL EVALUATION 53 55 69.71 $3485.72 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 109 127 141.85 $6879.84 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 92 111 112.37 $5449.79 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 132 148 158.31 $7678.24 $48.50
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Subtotal (Total Children Is Unduplicated) 276 452 493.25 $24027.08 $48.71
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 2.00 $100.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 139 148 216.56 $10828.13 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 63 66 95.49 $4774.54 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 50 51 77.86 $3893.11 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 79 83 108.27 $5413.35 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 4 4 1.86 $136.24 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 73 101 444.87 $11121.66 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 350 436 2166.92 $108345.99 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 162 195 690.74 $46887.48 $67.88
PHY -97110 PT SESSION BY LICENSED PT 165 205 837.07 $56820.38 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 6 6 2.67 $2.67 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 8 11 23.32 $1166.19 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 172 205 672.15 $45625.25 $67.88
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 278 322 1228.14 $614.07 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 7 9 21.77 $1088.34 $50.00
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Subtotal (Total Children Is Unduplicated) 522 1844 6589.68 $296817.38 $45.04
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Total 2296 7082.93 $320844.46 $45.30
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Number of Children (Unduplicated) With at Least One Authorization 536