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: 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
Service Coordination, Class # 01
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1 1.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 1 1 1.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 4 4 4.00 $240.00 $60.00
EXIT -EXIT TRANSITION ASSESSMENT 2 4 4.00 $200.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 31 39 40.00 $1940.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 8 10 10.00 $485.00 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 7 7 7.00 $350.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 29 34 34.00 $1649.00 $48.50
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Subtotal (Total Children Is Unduplicated) 71 98 99.00 $4864.00 $49.13
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 2 3.00 $4500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 1.40 $70.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 32 32 38.36 $1918.22 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 13 13 7.48 $374.17 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 11 11 8.33 $416.67 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 33 33 30.98 $1549.17 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 10.71 $267.86 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 83 95 439.44 $21971.89 $50.00
INTR -INTR INTERPRETER 1 1 2.00 $100.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 44 47 224.14 $15214.32 $67.88
PHY -97110 PT SESSION BY LICENSED PT 47 50 199.74 $13558.45 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 0.88 $47.98 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 2 2 1.82 $1.82 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 105 111 427.25 $29001.39 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 27.57 $363.94 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 154 240 83396.64 $41698.32 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 3.71 $185.72 $50.00
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Subtotal (Total Children Is Unduplicated) 189 648 84823.47 $131239.91 $1.55
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Total 747 84923.47 $136103.91 $1.60
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Number of Children (Unduplicated) With at Least One Authorization 212