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: 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
Service Coordination, Class # 01
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 2.79 $103.07 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 2.79 $103.07 $37.00
Screening, Eval, and Assessment, Class # 02
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 2 2 2.00 $250.00 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 7 9 9.00 $450.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 38 39 39.00 $1891.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 17 18 18.00 $873.00 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 6 6 6.00 $300.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 37 38 38.00 $1843.00 $48.50
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Subtotal (Total Children Is Unduplicated) 82 113 113.00 $5656.00 $50.05
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 3.00 $4500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 1.00 $50.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 0.87 $43.34 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 21 24 27.53 $1376.68 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 16 17 22.30 $1115.01 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.30 $32.50 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 15 16 18.06 $903.23 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 27 29 30.33 $1516.69 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.30 $32.50 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 0.86 $21.43 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 79 103 442.88 $22144.07 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 7.29 $364.29 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 48 53 322.79 $21910.70 $67.88
PHY -97110 PT SESSION BY LICENSED PT 61 72 337.43 $22904.82 $67.88
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 116 132 560.61 $38054.12 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 28.93 $381.86 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 159 254 98372.79 $49186.39 $0.50
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Subtotal (Total Children Is Unduplicated) 211 712 100179.26 $164537.60 $1.64
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Total 826 100295.05 $170296.67 $1.70
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Number of Children (Unduplicated) With at Least One Authorization 227