Summary Report for FSPSAs Initiated During the Report Period Center: 55
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
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 2.00 $120.00 $60.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 12 12 12.00 $582.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 17 17 17.00 $824.50 $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 19 19 18.35 $889.98 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 45 45 45.00 $2182.50 $48.50
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Subtotal (Total Children Is Unduplicated) 67 104 103.35 $5035.48 $48.72
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 6 6 19.14 $957.15 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1 1 1.80 $90.00 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 2 2 10.86 $542.86 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 20 23 167.78 $8389.05 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 51 53 346.61 $23527.68 $67.88
PHY -97110 PT SESSION BY LICENSED PT 36 38 246.86 $16756.66 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 0.14 $7.84 $54.32
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 88 94 560.43 $38041.71 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 1.43 $18.86 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 38 48 1869.06 $934.53 $0.50
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Subtotal (Total Children Is Unduplicated) 126 268 3225.11 $90766.34 $28.14
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Total 372 3328.46 $95801.81 $28.78
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Number of Children (Unduplicated) With at Least One Authorization 141