Summary Report for FSPSAs Initiated During the Report Period Center: 52
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
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
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 2.00 $120.00 $60.00
EXIT -EXIT TRANSITION ASSESSMENT 7 10 10.00 $500.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 29 33 33.00 $1600.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 13 15 15.00 $727.50 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 9 9 9.00 $450.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 34 38 38.00 $1843.00 $48.50
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Subtotal (Total Children Is Unduplicated) 76 107 107.00 $5241.00 $48.98
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.00 $3000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 1.00 $50.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 22 23 31.22 $1560.84 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 15 15 16.48 $824.18 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.30 $32.50 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 19 19 21.63 $1081.68 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 24 27 27.85 $1392.51 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.30 $32.50 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 12.29 $307.14 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 74 94 468.25 $23412.39 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 3.00 $150.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 47 51 334.92 $22734.15 $67.88
PHY -97110 PT SESSION BY LICENSED PT 60 71 360.86 $24495.48 $67.88
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 103 120 582.61 $39547.42 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 19.21 $253.63 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 165 275 111384.93 $55692.46 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 1.00 $50.00 $50.00
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Subtotal (Total Children Is Unduplicated) 192 706 113269.85 $174616.85 $1.54
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Total 814 113379.63 $179960.93 $1.59
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Number of Children (Unduplicated) With at Least One Authorization 211