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: 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
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 6.14 $767.86 $125.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 7 7 6.07 $294.24 $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 7 7 7.00 $339.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 9 9 9.00 $436.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 38 38 40.21 $1950.17 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 6.00 $600.00 $100.00
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Subtotal (Total Children Is Unduplicated) 56 80 91.42 $5212.76 $57.02
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 1.00 $50.00 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 2 2 4.67 $233.33 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 0.70 $35.00 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.19 $4.79 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 23 23 184.62 $9231.20 $50.00
INTR -INTR INTERPRETER 1 2 12.14 $607.14 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 47 48 327.47 $22228.78 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.57 $85.36 $54.32
PHY -97110 PT SESSION BY LICENSED PT 27 27 194.67 $13214.30 $67.88
PHY -97110HM PT SESSION BY PT ASST 4 4 8.07 $438.44 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 0.17 $0.17 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 65 66 510.36 $34643.05 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 12 12 66.71 $880.63 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 58 77 1472.61 $736.31 $0.50
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Subtotal (Total Children Is Unduplicated) 123 267 2785.96 $83888.49 $30.11
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Total 347 2877.38 $89101.25 $30.97
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Number of Children (Unduplicated) With at Least One Authorization 135