Summary Report for FSPSAs Ending During the Report Period Center: 55
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
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 5 5 5.00 $300.00 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.00 $119.60 $119.60
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 13 13 13.00 $630.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 20 20 20.00 $970.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 9 9 9.00 $436.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 18 18 18.00 $873.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 43 45 45.00 $2182.50 $48.50
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 68 111 111.00 $5512.10 $49.66
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 4 4 4.00 $200.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 2 2 2.09 $104.41 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 2.45 $122.26 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 1.57 $78.34 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 4 5 6.73 $336.55 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 2 4.86 $121.43 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 10.43 $521.43 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 25 29 191.43 $9571.44 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 67 70 456.32 $30975.09 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 13.43 $729.44 $54.32
PHY -97110 PT SESSION BY LICENSED PT 38 39 234.86 $15942.08 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 6.43 $349.20 $54.32
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 90 98 590.67 $40094.46 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 9.43 $124.46 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 27 33 876.86 $438.43 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 12.43 $621.43 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 119 296 2424.96 $101830.43 $41.99
-----------------------------------------------------------------------------------------------------------------------------
Total 407 2535.96 $107342.53 $42.33
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 138