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: 10/01/08 and 12/31/08 Date of Report: 02-16-09 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 12 13 15.86 $769.07 $48.50
EVAL -EVAL DEVELOPMENTAL EVALUATION 69 75 78.44 $3921.91 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 1 1 1.00 $50.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 87 95 95.00 $4607.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 75 78 107.18 $5198.05 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 117 122 129.52 $6281.67 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 7.57 $378.57 $50.00
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Subtotal (Total Children Is Unduplicated) 276 385 434.56 $21206.76 $48.80
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 6 6 7.57 $378.34 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 153 159 216.29 $10814.51 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 64 65 80.70 $4035.25 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 27 27 30.19 $1509.52 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 85 90 119.42 $5971.17 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 6 6 11.71 $860.06 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 84 91 317.65 $7941.18 $25.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 1 1 5.43 $271.43 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 311 340 1932.12 $96606.01 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 135 156 559.91 $38006.49 $67.88
PHY -97110 PT SESSION BY LICENSED PT 144 164 596.25 $40473.43 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 18 19 8.94 $8.94 $1.00
SENS -V5264 EARMOLD 1 1 1.00 $18.72 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 9 9 26.02 $1300.96 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 174 200 780.91 $53008.27 $67.88
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 265 317 1099.95 $549.97 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 5 6 18.46 $922.85 $50.00
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Subtotal (Total Children Is Unduplicated) 490 1657 5812.52 $262677.09 $45.19
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Total 2042 6247.08 $283883.85 $45.44
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Number of Children (Unduplicated) With at Least One Authorization 513