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: 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
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 9 9 9.00 $436.50 $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 6 6 6.00 $291.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 19 19 19.00 $921.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 44 45 45.00 $2182.50 $48.50
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 64 99 99.00 $4801.50 $48.50
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 3 10.71 $535.72 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 2 0.56 $13.96 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 4 4 33.29 $1664.29 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 21 21 107.38 $5368.81 $50.00
INTR -INTR INTERPRETER 1 1 4.57 $228.57 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 65 66 382.79 $25983.49 $67.88
PHY -97110 PT SESSION BY LICENSED PT 36 36 187.32 $12715.37 $67.88
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 88 90 528.00 $35840.63 $67.88
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 30 38 382.71 $191.36 $0.50
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 126 262 1638.33 $84042.19 $51.30
-----------------------------------------------------------------------------------------------------------------------------
Total 361 1737.33 $88843.69 $51.14
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 143